Acute care medicine. A community hospital practice.

This article describes the efforts of a group of anesthesiologists at Rex Hospital in Raleigh, North Carolina, to provide a wide range of anesthesiology and perioperative services. The group's philosophy that anesthesiologists are best positioned to provide such a range of services is exemplified by the work that this group performs in a 400-bed community hospital. The group's primary mission is to provide operating room anesthesia and comprehensive perioperative medicine services. This model of anesthesiologists' involvement is one example of the ways anesthesiologists can and should be involved in perioperative medicine and other acute care services in hospitals today to secure a brighter and more stable future for themselves and for their specialty.

The effect of feedback in learning clinical diagnosis.

There is evidence that students who are given information about how they appear to weight information in reaching a judgment can learn to make judgments more accurately. In teaching medical diagnosis, the present authors used a microcomputer system to generate simulated cases and then calculate the relationship between the data presented and the student's diagnosis. Students who were given feedback comparing their apparent weighting of clinical information with the correct weighting learned to diagnose urinary tract infection more accurately than control students who received feedback only on the outcome of their diagnosis.

Diagnosing pulmonary embolism using clinical findings.

To determine the value of clinical findings in the diagnosis of pulmonary embolism, we analyzed the records of 82 patients from three different hospitals who underwent pulmonary arteriography to rule out pulmonary embolism. We recorded 92 items of clinical information, including lung ventilation-perfusion scan results, for each patient. Although the diagnostic power of any single variable was marginal, an eight-item decision rule derived using discriminant analysis correctly predicted the outcome of arteriography in 82% of the cases. When tested on a different group of 68 patients from four hospitals, the rule accurately identified patients with low or high likelihood of having positive arteriograms. Clinical use of such a rule could reduce the need for arteriography in this population and would expedite decisions about anticoagulant therapy and further diagnostic testing.

How physicians use clinical information in diagnosing pulmonary embolism: an application of conjoint analysis.

To investigate what diagnostic strategies physicians adopt when the literature is unclear about the best use of diagnostic information, the authors examined how physicians weighted eight items of clinical information in diagnosing pulmonary embolism. Thirteen faculty members, 23 house officers, and 19 students estimated the likelihood of pulmonary embolism and predicted whether they would begin treatment in 27 simulated cases. The vignettes were constructed using a fractional factorial design and analyzed using conjoint analysis. Overall the lung scan results (34.7%) and leg examination (19.0%) were weighted most heavily in making the diagnosis, whereas the leg examination (35.7%) was given the greatest weight when deciding about therapy. Weights given by groups at different levels of training were similar, but there was considerable variation within groups. Heterogeneity of diagnostic strategies did not appear to decrease in groups with more training and experience. Multivariate analysis of predictors of pulmonary embolism in 102 actual cases showed that although lung scan results were important in both actual and simulated cases, heart rate accounted for the most variance in the actual cases but was hardly used in the physicians' strategies. There is considerable variation among physicians in how clinical information is used in diagnosing pulmonary embolism, and the variation may not decrease with increased experience.

Use of clinical findings in the diagnosis of urinary tract infection in women.

To develop a decision rule for predicting urinary culture results in patients suspected of having urinary tract infection, we used discriminant analysis to identify the optimum combination of clinical findings. Thirty variables identified in a pilot study were recorded from 248 patients in a second study. Five findings were independent predictors of positive urinary culture: history of urinary tract infection, back pain, microscopic pyuria, hematuria, and bacteriuria. An additive decision rule that assigned one point for each of the five variables was tested in a third group of 258 patients. These scores stratified patients into subsets with increasing likelihood of positive culture. Higher scores identified patients who can confidently be treated without documentation of bacteriuria. If the rule applies successfully to other populations, cost savings could result from identification of patients who do not require quantitative urinary culture to demonstrate significant bacteriuria.