Enhancing Physician's Toolkit: Integrating Storytelling in Medical Practice.

Traditional communication of medical literature using evidence-based terminologies are inadequate as the body of COVID-19 literature increases thereby requiring alternate methods of communication like podcasts, webinars, social media. A common theme in all these alternate forms of communication is the art of storytelling that allows physicians to make a connection with a patient by understanding their perspectives. Apart from few situations where story telling can be distracting in many situations where the patient's history is complex and require great listening skills and empathy.. Learning to be a good storyteller can help the physician help patients be a great change agent for them. Communicating with these patients can be done effectively using standard communication tools and using effective storytelling techniques can reinforce the patients trust in the provider and strengthen patient physician relationship. This could have a salutatory result both for the patient by increasing patient satisfaction and compliance with treatment and physician satisfaction by increasing to understand their patient's true concerns.

Perioperative Cardiovascular Medication Management in Noncardiac Surgery: Common Questions.

Several medications have been used perioperatively in patients undergoing noncardiac surgery in an attempt to improve outcomes. Antiplatelet therapy for primary prevention of cardiovascular events should generally be discontinued seven to 10 days before surgery to avoid increasing the risk of bleeding, unless the risk of a major adverse cardiac event exceeds the risk of bleeding. Antiplatelet therapy for secondary prevention should be continued perioperatively, except before procedures with very high bleeding risk, such as intracranial procedures. Antiplatelet drugs should be continued and surgery delayed, if possible, for at least 14 days after percutaneous coronary intervention without stent placement, 30 days after percutaneous coronary intervention with bare-metal stent placement, and six to 12 months after percutaneous coronary intervention with drug-eluting stent placement. Perioperative beta blockers are recommended for patients already receiving these agents, and it is reasonable to consider starting therapy in patients with known or strongly suspected coronary artery disease or who are at high risk of perioperative cardiac events and are undergoing procedures with a high risk of cardiovascular complications. Long-term statin therapy should be continued perioperatively or started in patients with clinical indications who are not already receiving statins. Clonidine should not be started perioperatively, but long-term clonidine regimens may be continued. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers generally can be continued perioperatively if patients are hemodynamically stable and have good renal function and normal electrolyte levels.

Communication Adaptations for a Diverse International Patient Population.

We live in an age of hyper connectivity, people from around the world are looking outside their own national borders to receive medical care. As more people are learning about the quality that the elite Indian hospitals provide at a competitive, and often more affordable, price compared to other institutions around the world, they are becoming increasingly interested in receiving their medical care in Indian hospitals. It is for this exact reason that it is very important to learn the importance of communicating effectively with people from a diverse background. Over the next decade, the number of international patients that Indian hospitals will provide care for is set to dramatically increase. In this new age of medicine in India, it is imperative that doctors are adequately equipped with the communication skills to appropriately connect with patients coming from very different cultural backgrounds. The interaction with an international patient can be tremendously deepened through effective communication that adheres to the cultural beliefs of the patient. In this article, we detail how to effectively communicate with people from different backgrounds. We explore how to speak with patients and connect on a deeper level and respect the cultural differences that exist. We will also discuss how to avoid offending your patients or miscommunicating your plans to them. Overall, improved awareness of cultural differences will ensure higher patient satisfaction as well as an improved doctor patient interaction.

Tidal variation of phytoplankton in the coastal waters of South Andaman, India.

Tidal variations of phytoplankton were studied at two stations i.e., Station 1 (Science Centre) and Station 2 (Junglighat Bay) during the period of December 2010 to February 2011 in the coastal waters of South Andaman Islands, India. Phytoplankton biomass (Chlorophyll-a) was observed low (avg. 0.02- 0.1 mg m(-3)) at the stations during the sampling period. Low values of dissolved oxygen and biochemical oxygen demand were recorded during low tide. In all 114 species belonging to 42 genera of diatoms, 16 genera of dinoflagellates and 4 genera of cyanobacteria were identified. Phytoplankton population density ranged from 827cells I(-1) to 11,790 cells l(-1) and was high during high tide in comparison to low tide. Diatoms were dominant (70.86-88.0%) and contributed more towards phytoplankton biomass followed by dinoflagellates (10.8-19.53%) and cyanobacteria (0.73-9.4%). Dinoflagellates were visualised more in the samples when diatom population had declined. Diversity indices such as species diversity (H') ranged from 0.68-3.1; species richness (d) varied from 2.18-6.54 and Pielou's evenness (J') ranged from 0.24-0.94. H' was more during high tide than at low tide at Station 2. On the other hand, low diversity and equitability in phytoplankton population were observed at Station 1 during the month of January, 2011. It may be due to dominance of mono specific cells of Rhizosolenia sp. The study indicates low production of phytoplankton in coastal waters. Variation of tides may leave implications on sampling, because it has an influence on species diversity and proportion of specific micro algal groups at different times.

Surgical Outcome of Basal Ganglia Hemorrhage: A Retrospective Analysis of Nearly 3,000 Cases over 10 Years.

Background Basal ganglia hemorrhage (BGH) is a severe neurologic condition associated with significant morbidity and mortality, and its optimal management remains a topic of debate. Our study assessed the surgical outcomes of BGH patients at the 3-month mark using the modified Rankin Scale (mRS). Methods This retrospective observational study was conducted over 10 years at an advanced neuro-specialty hospital in Eastern India, including patients who underwent decompressive craniotomy and hematoma evacuation. Variables were systematically coded and analyzed to evaluate the postoperative outcome with age (in years), preoperative motor (M) status, and hematoma volume. Results This study enrolled 2,989 patients with a mean age of 59.62 (standard deviation: 9.64) years, predominantly males ( n = 2,427; 81.2%). Hypertension (1,612 cases) and diabetes mellitus (1,202 cases) were the most common comorbidities. Common clinical presentations included ipsilateral weakness (1,920 cases) and/or altered mental status (1,670 cases). At the 3-month mark postsurgery, 2,129 cases (71.2%) had a favorable outcome based on mRS, while 389 cases (13.0%) had an unfavorable outcome. The regression equation showed that age was inversely related to the percentage of individuals achieving a favorable outcome. It also revealed that the preoperative motor score was positively correlated with favorable outcomes. Hematomas smaller than 60 mL had better outcomes, with 1,311 cases (69.1%) classified as good outcomes and 337 cases (17.8%) as bad outcomes. Fatal outcomes related to the illness were observed in 471 patients (15.8%) within the study population. Conclusion Surgery for BGH showed a substantial improvement in outcomes, particularly in patients with M5/M4 motor status. The preoperative motor score (M status) emerged as a crucial predictor of favorable neurological outcomes. Age and hematoma volume, however, were found to be nondefinitive factors in determining good outcomes.

Grace, Inspiration, Fulfillment, Timeless, Soulful (GIFTS): The Why and How of Podcasts for Recognition and Mentoring of Faculty in Medicine.

This commentary offers the reader an alternative to mentoring through the use of PODCASTS. By providing the listener with an understanding of the challenges and opportunities for self-reflection and sharing of experiences by the interviewees, we are impacting the listener attitudes and future goals through lessons learned.

Immunomodulatory activity of ethanol extract of Annona reticulata L. leaf in cultured immune cells and in Swiss albino mice.

BACKGROUND: Annona reticulata Linn, has been shown to possess antipyretic, antihelmintic, hypoglycemic, antiulcer and wound healing properties. However, its immunomodulatory role is yet to be explored. OBJECTIVE(S): In the present study, we intended to investigate the effects of A. reticulata leaf ethanol extract on various components of the immune system. MATERIAL AND METHODS: The effects of A. reticulata leaf extract on human peripheral blood mononuclear cells, monocyte (THP1), and human macrophage (U937) cell lines were investigated. An animal study was conducted to observe the effect of the extract on humoral as well as cell mediated immunity. RESULTS: The extract stimulated proliferation of human PBMC, monocytes (THP1), and macrophages (U937) significantly in a dose dependent manner; expression of transforming growth factor-beta (TGF-ß) increased in western blot analysis. Additionally, the extract treated macrophages exhibited features of activation under the microscope with a significant hike in the NO production. Flow cytometry of extract treated human PBMC revealed increased proliferation of lymphocytes (CD4, CD8 & B-cells) along with enhanced intracellular expression of IL-2, IL-6. Animal study data indicate a significant rise in the antibody titer as well as a strong delayed type hypersensitivity response in the extract (150 mg/kg and 300 mg/kg) treated mice; furthermore, the expression of IL-2 and IL-6 in mice PBMC was augmented. CONCLUSION: The collective data evince the immunomodulatory potential of A. reticulata L. leaf.

Effects of emollient therapy with sunflower seed oil on neonatal growth and morbidity in Uttar Pradesh, India: a cluster-randomized, open-label, controlled trial.

BACKGROUND: Newborn oil massage is a widespread practice. Vigorous massage with potentially harmful products and forced removal of vernix may disrupt skin barrier integrity. Hospitalized, very-preterm infants treated with sunflower seed oil (SSO) have demonstrated improved growth but community-based data on growth and health outcomes are lacking. OBJECTIVES: We aimed to test whether SSO therapy enhances neonatal growth and reduces morbidity at the population level. METHODS: We conducted an open-label, controlled trial in rural Uttar Pradesh, India, randomly allocating 276 village clusters equally to comparison (usual care) and intervention comprised of promotion of improved massage practices exclusively with SSO, using intention-to-treat and per-protocol mixed-effects regression analysis. RESULTS: We enrolled 13,478 and 13,109 newborn infants in demographically similar intervention and comparison arms, respectively. Adherence to exclusive SSO increased from 22.6% of intervention infants enrolled in the first study quartile to 37.2% in the last quartile. Intervention infants gained significantly more weight, by 0.94 g · kg-1 · d-1 (95% CI: 0.07, 1.82 g · kg-1 · d-1, P = 0.03), than comparison infants by intention-to-treat analysis. Restricted cubic spline regression revealed the largest benefits in weight gain (2-4 g · kg-1 · d-1) occurred in infants weighing <2000 g at birth. Weight gain in intervention infants was higher by 1.31 g · kg-1 · d-1 (95% CI: 0.17, 2.46 g · kg-1 · d-1; P = 0.02) by per-protocol analysis. Morbidities were similar by intention-to-treat analysis but in per-protocol analysis rates of hospitalization and of any illness were reduced by 36% (OR: 0.64; 95% CI: 0.44, 0.94; P = 0.02) and 44% (OR: 0.56; 95% CI: 0.40, 0.77; P < 0.001), respectively, in treated infants. CONCLUSIONS: SSO therapy improved neonatal growth, and reduced morbidities when applied exclusively, across the facility-community continuum of care at the population level. Further research is needed to improve demand for recommended therapy inside hospital as well as in community settings, and to confirm these results in other settings.This trial was registered at www.isrctn.com as ISRCTN38965585 and http://ctri.nic.in as CTRI/2014/12/005282.

Identification and management of chronic kidney disease complications by internal medicine residents: a national survey.

Many patients with chronic kidney disease (CKD) receive care from primary care physicians. Identification and management of CKD complications in primary care is suboptimal. It is not known if current residency curriculum adequately prepares a future internist in this aspect of CKD care. We performed an online questionnaire survey of internal medicine residents in the United States to determine knowledge of CKD complications and their management. Four hundred seventy-nine residents completed the survey with postgraduate year (PGY) distribution 166 PGY1, 187 PGY2, and 126 PGY3. Most of the residents correctly recognized anemia (91%) and bone disease (82%) as complications at estimated glomerular filtration rate less than 60 mL/min/1.73 m; however, only half of the residents identified coronary artery disease (54%) as a CKD complication. For a patient with estimated glomerular filtration rate less than 60 mL/min/1.73 m, two thirds of the residents would workup for anemia (62%), whereas half of them would check for mineral and bone disorder (56%). With regard to anemia of CKD, less than half of the residents knew the CKD goal hemoglobin level of 11 to 12 g/dL (44%); most would supplement iron stores (86%), whereas fewer would consider nephrology referral (28%). For mineral and bone disorders, many residents would recommend dietary phosphorus restriction (68%) and check 25-hydroxyvitamin D (62%); fewer residents would start 1,25-dihydroxyvitamin D (40%) or refer to the nephrologist (45%). Residents chose to discontinue angiotensin-converting enzyme inhibitor for medication-related complication of greater than 50% decline in estimated glomerular filtration rate (68%) and potassium greater than 5.5 mEq/L (93%). Mean performance score improved with increasing PGY (PGY1 59.4% ± 17.6%, PGY2 63.6% ± 15.6%, and PGY3 66.2% ± 16.5%; P = 0.002). Our study identified specific gaps in knowledge of CKD complications and management among internal medicine residents. Educational efforts such as instruction on use of CKD clinical practice guidelines may help raise awareness of CKD complications, benefits of early intervention, and improve CKD management.

Evaluation of wound healing activity of ethanol extract of Annona reticulata L. leaf both in vitro and in diabetic mice model.

BACKGROUND AND AIM: The leaves of AnnonareticulataLinn (niú x inguǒ; Bullock's heart), a member of Annonaceae family, have been used extensively in folk medicine; however, its wound healing potential is yet to be explored. Our aim was to investigate the wound healing ability of A. reticulataleaf extract in vitro and in streptozotocin induced diabetic mice model. MATERIAL AND METHODS: We observed the plant extract induced proliferation and migration of primary human dermal fibroblast (HDF), human skin fibroblast cell line (GM00637) and human keratinocyte cell line (HACAT). The expression of transforming growth factor beta (TGF-ß), connective tissue growth factor (CTGF), vascular endothelial growth factor (VEGF), alpha smooth muscle actin (α-SMA), matrix metalloproteinases (MMP-2, MMP-9), collagen-1, collagen-3, focal adhesion kinase (FAK) were evaluated by Western blot and gelatin zymography. Excisional diabetic wound model was used for in vivo wound healing assay. Furthermore, we processed wound tissue for histological and immunohistochemical study. RESULT: A. reticulata L. leaf extract stimulates proliferation and migration of HDF, skin fibroblast and keratinocyte significantly in a dose dependent manner; expression of TGF-ß, CTGF, VEGF, α-SMA, MMP-2, MMP-9, collagen-1, collagen-3, FAK increased. Additionally, an enhanced expression of phospho-SMAD2, phospho-SMAD3 in the treated cells indicated the activation of TGF-ß signal transduction pathway, similarly increased expression of phospho-AkT suggested activation of PI3/AkT pathway. Expression of CTGF and α-SMA was also increased significantly in wound tissue. Mass spectrometric analysis revealed that mainly two compounds to be present in the extract: quercetin and ß-sitosterol. CONCLUSION: Collective data suggest that A.reticulata leaf extract may have a stimulatory effect in diabetic wound healing.

Complementary and Alternative Medicine Use by Patients From the Gulf Region Seen in the International Practice of a Tertiary Care Medical Center.

BACKGROUND: Patients from various countries may have unique patterns of using complementary and alternative medicine (CAM) and unique reasons for using it. OBJECTIVE: Our objective was to assess the use of CAM among patients from the Gulf region attending the Executive and International Health Program of the Department of General Internal Medicine at Mayo Clinic in Rochester, Minnesota. METHODS: This cross-sectional survey was administered to all patients who were from the Gulf region and were undergoing outpatient evaluation in the Executive and International Health Program. After their initial medical evaluation by a physician, the patients were invited to anonymously complete the modified International Complementary and Alternative Medicine Questionnaire. RESULTS: The survey was completed by 69 patients (41 women, 27 men; mean age, 45.4 years). The most frequently seen providers for CAM treatments were physicians (71.0% of patients), spiritual healers (29.0%), and chiropractors (20.3%). CAM treatments most frequently received from a physician were massage therapy (51.0%), hijama (38.8%), spiritual healing (24.5%), and acupuncture or herbs (16.3%). The most frequently used dietary supplements were ginger (42.0%), bee products (30.4%), and garlic (27.5%). The most common self-help therapies were prayers for health (68.1%), meditation (15.9%), and relaxation techniques (11.6%). CAM therapy, including visits to CAM providers, was used by 92.8% of patients. CAM was mainly used to improve well-being and long-term health conditions rather than for acute illnesses. CONCLUSION: The use of CAM was high among our patients from the Gulf region, and the CAM therapies used by this population differed from the ones used by US patients. Physicians providing care to patients from the Gulf region should be aware of how the use of CAM may affect the care needs of these patients.

Tools to manage medical uncertainty.

BACKGROUND AND AIMS: Despite an explosion of evidence-based guidelines, many decisions in clinical practice remain shrouded in uncertainty. Physicians could view ambiguous situations as a source of threat. Uncertainty results from personal lack of knowledge, limits of current medical knowledge and the inability to distinguish between the two. The purpose of this review is to study the prevalence, effects and management of medical uncertainty in clinical practice. METHODS: PubMed search for articles on prevalence and management of medical uncertainty. RESULTS AND CONCLUSION: Intolerance to uncertainty among physicians may result in increased test-ordering tendencies, failure to comply with evidence-based guidelines, guide career choices, and result in decreased comfort with geriatric, chronic illness and psychological problems. Factors causing variability of disease management includes: patient factors(inappropriate prioritization, risk aversion, expectations), physicians factors(lack of knowledge, intolerance to medical uncertainty, limited resources, time constraints), biological variability of patient, health system factors, patients comorbidities, technological and media influences contributing further to unrealistic expectations. Physicians' perceptions of uncertainty in their daily work vary considerably. Urologist and orthopedic surgeons reported less uncertainty in their daily routine compared to psychiatrists, family practitioners and general internists. Effective methods of managing uncertainty include, consensus building among physicians from 3 or more specialties regarding patients problem, building trust between patients, their physicians and health care systems, thoughtful evaluation with exclusion of worrisome diagnosis, apply evidence-based information with effective risk communication, negotiating management strategies with patient and establishing regular follow-up with personalized feedback. (- 245 words).

Qualitative assessment of innovations in healthcare provision.

BACKGROUND: The triad of quality, innovation and economic restraint is as important in health care as it is in the business world. There are many proposals for the assessment of quality and of economic restraints in health care but only a few address assessment of innovations. We propose a strategy and new structures to standardize the description of health care innovations and to quantify them. DISCUSSION: Strategy and structure are based on the assumption that in the early phase of an innovation only data on the feasibility and possibly on the efficacy or effectiveness of an innovation can be expected. From the patient's perspective, benefit resulting from an innovation can be confirmed only in a later phase of development. Early indicators of patient's benefit will be surrogate parameters which correlate only weakly with the desired endpoints. After the innovation has been in use, there will be more evidence on correlations between surrogate parameters and the desired endpoints to provide evidence of the patient benefit. From an administrative perspective, this evidence can be considered in decisions about public financing. Different criteria are proposed for the assessment of innovations in prevention, diagnosis and therapy. For decisions on public financing a public fund for innovations may be helpful. Depending on the phase of innovation risk sharing models are proposed between manufacturers, private insurers and public funding. SUMMARY: Potential for patient benefit is always uncertain during early stages of innovations. This uncertainty decreases with increasing information on the effects of the innovation. Information about an innovation can be quantified, categorized and integrated into rational economic decisions.

Awareness and knowledge of clinical practice guidelines for CKD among internal medicine residents: a national online survey.

BACKGROUND: The National Kidney Foundation published Kidney Disease Outcomes Quality Initiative guidelines that recommend early detection and management of chronic kidney disease (CKD) and timely referral to a nephrologist. Many patients with CKD are seen by primary care physicians who are less experienced than nephrologists to offer optimal pre-end-stage renal disease care. It is not known whether current postgraduate training adequately prepares a future internist in CKD management. STUDY DESIGN: Cross-sectional study using an online questionnaire survey. SETTING & PARTICIPANTS: Internal medicine residents in the United States (n = 479) with postgraduate year (PGY) distribution of 166 PGY1, 187 PGY2, and 126 PGY3. PREDICTOR: Awareness and knowledge of CKD clinical practice guidelines measured by using the questionnaire instrument. OUTCOMES & MEASUREMENTS: Total performance score (maximum = 30). RESULTS: Half the residents did not know that the presence of kidney damage (proteinuria) for 3 or more months defines CKD. One-third of the residents did not know the staging of CKD. All residents (99%) knew the traditional risk factors for CKD of diabetes and hypertension, but were less aware of other risk factors of obesity (38%), elderly age (71%), and African American race (68%). Most residents (87%) were aware of estimated glomerular filtration rate in the evaluation of patients with CKD. Most residents (90%) knew goal blood pressure (<130/80 mm Hg) for patients with CKD. Most residents identified anemia (91%) and bone disorder (82%) as complications of CKD, but only half recognized CKD as a risk factor for cardiovascular disease. Most residents (90%) chose to refer a patient with a glomerular filtration rate less than 30 mL/min/1.73 m(2) to a nephrologist. A small improvement in mean performance score was observed with increasing PGY (PGY1, 68.8% +/- 15.4%; PGY2, 72.9% +/- 14.7%; and PGY3, 74.0% +/- 12.0%; P = 0.004). LIMITATIONS: Self-selection, lack of nonrespondent data. CONCLUSIONS: Our survey identified specific gaps in knowledge of CKD guidelines in internal medicine residents. Educational efforts in increasing awareness of these guidelines may improve CKD management and clinical outcomes.

Frequency format diagram and probability chart for breast cancer risk communication: a prospective, randomized trial.

BACKGROUND: Breast cancer risk education enables women make informed decisions regarding their options for screening and risk reduction. We aimed to determine whether patient education regarding breast cancer risk using a bar graph, with or without a frequency format diagram, improved the accuracy of risk perception. METHODS: We conducted a prospective, randomized trial among women at increased risk for breast cancer. The main outcome measurement was patients' estimation of their breast cancer risk before and after education with a bar graph (BG group) or bar graph plus a frequency format diagram (BG+FF group), which was assessed by previsit and postvisit questionnaires. RESULTS: Of 150 women in the study, 74 were assigned to the BG group and 76 to the BG+FF group. Overall, 72% of women overestimated their risk of breast cancer. The improvement in accuracy of risk perception from the previsit to the postvisit questionnaire (BG group, 19% to 61%; BG+FF group, 13% to 67%) was not significantly different between the 2 groups (P = .10). Among women who inaccurately perceived very high risk (> or = 50% risk), inaccurate risk perception decreased significantly in the BG+FF group (22% to 3%) compared with the BG group (28% to 19%) (P = .004). CONCLUSION: Breast cancer risk communication using a bar graph plus a frequency format diagram can improve the short-term accuracy of risk perception among women perceiving inaccurately high risk.

Disorders of calcium, phosphorus and magnesium metabolism.

Abnormalities of calcium, magnesium and phosphorus are common in hospitalized patients. Infrequently patients might present in the outpatient settings with non-specific symptoms that might be due to abnormalities of divalent cation (magnesium, calcium) or phosphorous metabolism. Several inherited disorders have been identified that result in renal or intestinal wasting of these elements. Physicians need to have a thorough understanding of the mechanism of calcium, magnesium and phosphorous metabolism and diagnoses disorders due to excess or deficiency of these elements. Prompt identification and treatment of the underlying disorders result in prevention of serious morbidity and mortality.

Disorders of potassium homeostasis: pathophysiology and management.

Disorders of potassium homeostasis are common electrolyte abnormalities encountered in hospitalized patients. Hypokalemia and hyperkalemia have been estimated to occur in about 21% and 3% of hospitalized patients, respectively; though the morbidity and mortality associated with the latter is significantly higher. Potassium is a predominantly intracellular ion and the understanding of its dynamics between intra- and extracellular fluid milieus, along with its handling by the kidneys, is important in the diagnosis and treatment of potassium disorders. This article aims to provide a clinically relevant update on management of potassium disorders for internists.

The association between impact factors and language of general internal medicine journals.

BACKGROUND: We sought to determine the associations between journal country of origin and language and journal impact factor of general medicine journals. METHODS: For each "Medicine, General and Internal" journal listed in the Institute for Scientific Information (ISI) Journal Citation Reports (JCR), the 2003 impact factor, language (ie, English, multiple languages [including English], or non-English), and country of origin (ie, US or non-US) were determined. The mean log impact factors of the journals by language, country of origin, and a combination of country of origin and language were compared. RESULTS: Of the 102 "Medicine, General and Internal" journals listed in the ISI JCR, 41 (40%) were published in the US and 83 (81%) were published in English. English-language journals had a significantly greater 2003 mean log impact factor than non-English journals and journals originating in the US had a significantly greater impact factor than journals originating elsewhere. However, the mean log impact factor of English-language journals originating in the US did not differ significantly from that of English-language journals originating elsewhere. CONCLUSION: Journal impact factor is more associated with journal language (ie, English versus non-English), rather than journal country of origin.

Impact of FUTON and NAA bias on visibility of research.

OBJECTIVE: To determine whether availability of journals on MEDLINE as FUTON (full text on the Net) affects their impact factor. MATERIAL AND METHODS: A comprehensive search identified 324 cardiology, nephrology, and rheumatology/immunology journals on-line until May 2003. The status of these journals was ascertained in MEDLINE as having FUTON, abstracts only, and NAA (no abstract available). Impact factors for all available journals from the Institute for Scientific Information (ISI) were abstracted. RESULTS: Of the 324 Journals, 124 (38.3%) were FUTON, 138 (42.6%) had abstracts only, and 62 (19.1%) had NAA. The mean (+/-SEM) impact factor was 3.24 (+/-0.32), 1.64 (+/-0.30), and 0.14 (+/-0.45), respectively. Of the 324 current journals, 159 existed in both the pre- and the post-Internet era. An analysis of the change (ie, delta) in impact factor from the pre- to post-Internet era revealed a trend between journals with FUTON and abstracts only (P=.17, Wilcoxon rank sum test). Similar analyses of the delta of cardiology journals revealed a statistically significant difference between Journals with FUTON and abstracts only (P=.04, Wilcoxon rank sum test). CONCLUSION: FUTON bias is the tendency to peruse what is more readily available. This is the first study to show that on-line availability of medical literature may increase the impact factor and that such increase tends to be greater in FUTON journals. Failure to consider this bias may affect a journal's impact factor. Also, it could limit consideration of medical literature by ignoring relevant NAA articles and thereby influence medical education akin to publication or language bias.

Dealing with medical uncertainty: a physician's perspective.

Uncertainty in diagnosis is frequently encountered in medical practice and causes stress in patients and physicians. Factors contributing to uncertainty include biological variability of patients, patient and physician bias, error in test interpretation, differing values and opinions of patients and physicians, and uncertainty surrounding decision-making. Physicians differ in their ability to tolerate uncertainty, and this varying tolerance has been linked with choice of specialty, increased test ordering, personal anxiety, increased cost of providing medical care, and decreased comfort with geriatric patients and patients with psychological problems. We review the current evidence for and effects of physician uncertainty in medical practice. Although uncertainty in practice cannot be completely eliminated, numerous strategies can be adopted to decrease uncertainty and enhance patients' trust. These include applying the best-available evidence-based information along with observance of core clinical practices, including meticulous history taking, excluding worrisome diagnoses, and involvement in shared decision-making.