Behind the surgery doors. A look at what English general practitioners do

Since 1969, the Meningomyelocele Clinic at British Columbia's Children's Hospital has been serving the needs of children with spina bifida. In 1994, the clinic provided urgent and routine multidisciplinary clinical assessments to 330 patients and families. The purpose of this study was to assess, from the patients' and families' perspective, the appropriateness of the frequency of routine clinic visits and the value of the health services provided. Sixty-five patients/families were interviewed and completed a questionnaire developed by the clinic. Current visit frequency and services provided appear to meet the patient/family needs. The medical and nursing contributions were seen as valuable resources for the patient/families resulting in most patient/families feeling well informed about spina bifida.     

Sharing care: the psychiatrist in the family physician's office

OBJECTIVE: One way of strengthening ties between primary care providers and psychiatrists is for a psychiatrist to visit a primary care practice on a regular basis to see and discuss patients and to provide educational input and advice for family physicians. This paper reviews the experiences of a program in Hamilton, Ontario that brings psychiatrists and counsellors into the offices of 88 local family physicians in 36 practices. METHOD: Data are presented based on the activities of psychiatrists working in 13 practices over a 2-year period. Data were gathered from forms routinely completed by family physicians when making a referral and by psychiatrists whenever they saw a new case. An annual satisfaction questionnaire for all providers participating in the program was also used to gather information. RESULTS: Over a 2-year period, 1021 patients were seen in consultation by one full-time equivalent psychiatrist. The average duration of a consultation was 51 minutes, and a family member was present for 12% of the visits. Twenty-one percent of the patients were seen for at least one follow-up visit, 75% of which were prearranged. In addition, 1515 cases were discussed during these visits without the patient being seen. All participants had a high satisfaction rating for their involvement with the project. CONCLUSIONS: Benefits of this approach include increased accessibility to psychiatric consultation, enhanced continuity of care, support for family physicians, and improved communication between psychiatrists and family physicians. This model, which has great potential for innovative approaches to continuing education and resident placements, demands new skills of participating psychiatrists.     

Phenotype expression of gingival fibroblasts cultured on membranes used in guided tissue regeneration

BACKGROUND: While the importance of providing individualised communication to cancer patients is now well recognised, little is known about the stability and validity of patients' expressed preferences for information and involvement in decision-making. This study explored the stability and possible predictors of such preferences over time. PATIENTS AND METHODS: Cancer patients seeing two Medical Oncologists in an out-patient clinic at an Australian teaching hospital completed a questionnaire battery before and directly after one consultation, and before their next consultation. Eighty consecutive patients with heterogeneous cancers participated in the study. Preferences for general and specific information, involvement and support were elicited at each assessment. Locus of control and patient familiarity with the clinic were measured before the first consultation. Patient satisfaction with the consultation was assessed directly after the consultation. Demographic and disease data were recorded for each patient. RESULTS: General preferences for information and involvement were relatively stable, at least in the short term; however there was considerable variability in preferences for specific topics of information. Patients whose condition had recently worsened were more likely to want progressively less involvement in decision-making. Gender, the doctor seen and religion were also predictive of patient preferences. CONCLUSIONS: Situational factors, such as change in disease status, may alter a patient's preferences for information and involvement. If we wish to match the provision of information and support to the expressed needs of patients, we must ask patients at each consultation what those needs are.     

Patients' health as a predictor of physician and patient behavior in medical visits. A synthesis of four studies

OBJECTIVES: Although some patient characteristics are known to be related to physician and patient communication in medical encounters, very little is known about the impact of patients' health status on communication processes. The authors assess relations of patients' physical and emotional health status to verbal and nonverbal communication between physicians and patients in four original studies, and combine results across the four studies using meta-analytic procedures. METHODS: In four original studies of routine outpatient visits (consisting of more than 250 physicians and more than 1,300 patients), health status was measured and audiotape or videotape records were coded for verbal content and nonverbal cues indicating task-related behavior and affective reactions on the part of both the physician and the patient. Both physical and mental health data were obtained, using physicians and/or patients as sources; in two studies, physicians' satisfaction with the visit also was measured. All available background characteristics for both physicians and patients were controlled via partial correlations. The meta-analytic procedures used were the unweighted and weighted (by sample size) average partial correlations, the combined P across studies (Stouffer method), and the test of effect size heterogeneity. RESULTS: Physicians showed signs of negative response to sicker or more emotionally distressed patients, both in their behavior and in their ratings of satisfaction with the visit. Sicker patients also behaved more negatively than healthier patients. However, physicians also engaged in a variety of positive and professionally appropriate behaviors with the sicker or more distressed patients. This mixed pattern of responses is discussed in terms of alternative frameworks: the physician's goals, reciprocation of affect, and ambivalence on the part of the physician. CONCLUSIONS: The patient's health status appears to influence physician-patient communication. In clinical practice, increased attention by physicians to their own and their patients' behavior may enhance diagnosis and prevent misunderstandings.     

Diagnosis and course of early-onset arthritis: results of a special early arthritis clinic compared to routine patient care

OBJECTIVE: Early arthritis patients referred to an Early Arthritis Clinic (EAC) (n = 233) were compared to 241 patients from the routine out-patient clinic with respect to lag time between the onset of symptoms and the visit to the rheumatologist, clinical presentation and the consistency of the diagnosis after 1 yr. RESULTS: The reduction in median lag time for the EAC patients was at least 3 months. An insidious onset of symptoms was found more often in the rheumatoid arthritis (RA) patients in the routine clinic. In 70% of all cases, a diagnosis could be made after 2 weeks and, if the clinical diagnosis was definite RA, this hardly changed during the following year. Early erosions were seen in 25% of RA patients and were associated with a positive rheumatoid factor (OR 2.08, 95% CI 0.95 4.59). CONCLUSION: An early diagnosis of RA at the EAC is possible and reliable; the high frequency of erosions illustrates the need for early treatment.     

A pilot study exploring the effect of discharging cancer survivors from hospital follow-up on the workload of general practitioners

BACKGROUND: The tradition of routine, long-term follow-up of cancer patients in the outpatient clinic has led to busy clinics and long waiting times. Many cancer patients are anxious and have become dependent on the specialist clinic for reassurance. General practitioners (GPs) have been shown to be willing to assume greater responsibility for the routine follow-up of breast cancer patients, but patients have demonstrated a preference for hospital follow-up. If patients are discharged unwillingly, their rehabilitation may be at the cost of an increased demand on GP practices. AIM: To determine the consequences for GPs of discharging long-term cancer patients from a hospital outpatient follow-up clinic. METHOD: A consecutive sample of 65 patients under annual review in a hospital oncology clinic were offered a planned discharge in which their return to the clinic, if necessary, was guaranteed. The 41 patients who accepted discharge were monitored. Anxiety and depression rates were assessed using the Hospital Anxiety and Depression Scale (HADS) at the time of discharge and four months later at a home interview. The GPs of all patients who were discharged were sent questionnaires four and twelve months after discharge to evaluate consultation rates and change in psychological morbidity. RESULTS: The results showed no significant increase in the consultation rates during the 12 months after discharge compared with the previous 12 months. There was no significant change in the level of patients' anxiety or depression at four months after discharge. The great majority of GPs (71%) reported no change in their perception of patients' levels of anxiety or depression. GPs thought there was a need for more specialist Macmillan nurses working in the community and highlighted the importance of fast-track specialist referral. CONCLUSION: Discharging this group of long-term cancer survivors did not increase the workload of GPs. However, GPs' concern over the lack of availability of Macmillan nurses in the community suggests that primary care services may find it difficult to cope adequately with the special requirements involved in cancer patient care. Finally, there is a need to address the further training requirements of GPs in the routine follow-up of cancer patients.     

Androgen receptor gene mutations in prostate cancer. Implications for disease progression and therapy

Increasing numbers of cancer survivors and the tradition of long-term follow-up in the outpatient clinic has resulted in overcrowded oncology clinics and long waiting times. Little is known about patients' perceptions of their clinic attendance. This survey of 252 oncology patients investigated patients' satisfaction with the clinic, anxiety associated with clinic attendance and the strengths and weaknesses of the oncology service. Results demonstrated high levels of satisfaction. Far from being perceived as anxiety-provoking, the clinic was looked upon as a valuable source of reassurance, 92% of patients reporting they were 'always' or 'usually' reassured as a consequence of their visit. Qualitative data showed that clinic staff were the most important source of satisfaction. Waiting was overwhelmingly the worst aspect of the clinic, described by 27% of patients as 'excessively long'. One-fifth of the total sample had attended the clinic for 10 years or more and over a third of this group reported they would be worried at the prospect of being discharged to the care of their general practitioners. Despite disadvantages associated with long waits, the clinic was perceived as providing a valuable source of reassurance which a proportion of patients were clearly reluctant to be without.     

Factors influencing outcome in consultations for chronic pelvic pain

We aimed to document the demographic and clinical characteristics of women referred by primary care physicians for investigation of chronic pelvic pain to a university hospital gynecology outpatient clinic and to test the hypothesis that specific patient features and the quality of doctor/patient communication at the initial consultation would influence pain outcomes. A clinical questionnaire, visual analog scales for pain, and instruments for hostility and the experience of the consultation were administered at the initial clinic attendance to 105 consecutive women. Follow-up pain scores were obtained 6 months later from 98 women. The mean hostility score was highly significantly elevated compared with normative data (p < 0.001). In a logistic regression model, a favorable patient rating of the initial consultation was associated with complete recovery at follow-up and interacted significantly with whether or not exercise was impaired (p < 0.005). For those in whom symptoms persisted, significant factors found by multiple regression models to predict continuing pain levels were the initial level of pain, the number of functions of daily life impaired, endometriosis, and the doctor who carried out the initial consultation. Patient hostility scores and the doctor's level of experience or gender were not significantly associated with continuing pain. This study highlights the importance of good communication as a basis for successful treatment of a group of hostile patients and indicates the influence in individual doctors of subtle attitudinal and personality factors that modify patients' experience of the medical consultation.     

The Functional Assessment of Cancer Therapy scale: development and validation of the general measure

PURPOSE: We developed and validated a brief, yet sensitive, 33-item general cancer quality-of-life (QL) measure for evaluating patients receiving cancer treatment, called the Functional Assessment of Cancer Therapy (FACT) scale. METHODS AND RESULTS: The five-phase validation process involved 854 patients with cancer and 15 oncology specialists. The initial pool of 370 overlapping items for breast, lung, and colorectal cancer was generated by open-ended interview with patients experienced with the symptoms of cancer and oncology professionals. Using preselected criteria, items were reduced to a 38-item general version. Factor and scaling analyses of these 38 items on 545 patients with mixed cancer diagnoses resulted in the 28-item FACT-general (FACT-G, version 2). In addition to a total score, this version produces subscale scores for physical, functional, social, and emotional well-being, as well as satisfaction with the treatment relationship. Coefficients of reliability and validity were uniformly high. The scale's ability to discriminate patients on the basis of stage of disease, performance status rating (PSR), and hospitalization status supports its sensitivity. It has also demonstrated sensitivity to change over time. Finally, the validity of measuring separate areas, or dimensions, of QL was supported by the differential responsiveness of subscales when applied to groups known to differ along the dimensions of physical, functional, social, and emotional well-being. CONCLUSION: The FACT-G meets or exceeds all requirements for use in oncology clinical trials, including ease of administration, brevity, reliability, validity, and responsiveness to clinical change. Selecting it for a clinical trial adds the capability to assess the relative weight of various aspects of QL from the patient's perspective.     

"Trust Me...": Psychological and Behavioral Predictors of Perceived Physician Empathy.

A sociocognitive model of distal and proximal predictors of empathic judgments was tested among 100 physicians. The authors hypothesized that physician perceived control would affect empathy ratings via physician communication style. Specifically, physicians with high perceived control would use more open communication and be rated as more empathic. Physicians with low perceived control would use a controlling communication style and be rated as less empathic. Physicians completed a medical attribution questionnaire prior to a structured patient consultation exercise, during which patients and assessors rated physician empathy. The exercise was audiotaped, transcribed, and content analyzed for verbal behaviors. Support was found for the hypotheses; however, patients, but not medical assessors, associated empathy with reassurance and provision of medical information. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessment of quality of life among pediatric patients with cancer.

Historical foundations of quality of life (QL) assessment, including those in adult oncology, are reviewed in the context of the current need for a developmental measure for clinical pediatric research. QL measures that can be applied to the assessment of children with cancer and other chronic and life-threatening diseases are urgently needed. Use of valid QL scales would facilitate the evaluation of patient status over time as well as the comparison of results of patients with different diagnoses, treatment histories, and outcomes of therapy. The attributes of an effective QL measure, based on clinical experience in pediatric oncology settings, include simplicity and brevity as well as conventional psychometric properties. Psychologists, in collaboration with their pediatric oncologist colleagues, are encouraged to develop new QL assessment methods. Suggestions are given for studies necessary to accomplish this goal. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Transgenic rice plants harboring an introduced potato proteinase inhibitor II gene are insect resistant

BACKGROUND: Previous studies suggest that injury prevention counseling by pediatricians is effective but accomplished infrequently. The Framingham Safety Surveys (FSS) are brief questionnaires designed to facilitate physician education of parents regarding injury prevention. OBJECTIVE: To determine whether the FSS improve pediatricians' injury prevention counseling. DESIGN: Nonrandomized comparison of a 4-week baseline period and subsequent intervention periods. SETTINGS: Private practice; university hospital clinic. PATIENTS: Patients coming for health supervision visits. INTERVENTION: Provision to the physician of one of the FSS, completed by the parent just before the health supervision visit. OUTCOME MEASURES: (1) After each visit parents completed a checklist of safety issues discussed by the pediatrician. Injury prevention was compared for the two periods by means of three criteria: number of issues discussed (quantity), identification and discussion of specific high-risk behaviors (efficiency), and recognition of high-risk families (targeting). (2) Each physician's assessment of the value of the FSS was obtained by questionnaire. RESULTS: A total of 144 parents (50 from the private practice, 94 from the clinic) completed checklists during the baseline period, and 168 (38 from the private practice, 130 from the clinic) during the intervention period. Use of the FSS produced no detectable improvement in any of the three measures. Seventy-seven percent of the physicians indicated that the FSS were helpful in educating families about safety, 38% thought that the FSS helped identify high-risk families, and 54% said they would use it again. CONCLUSIONS: Although most physicians believed the FSS were useful, introduction of the surveys as employed in this study did not improve injury prevention counseling.     

Evaluation of the quality of filling out medical records in a hypertension consultation

The aim of the study was to evaluate the completion of medical records of a hypertension clinic and to compare standardized computerized records versus standard medical records. The medical records of 163 consecutive hypertensive patients attending at the Broussais hospital hypertension clinic between December 1995, 6th and January 1996, 21st were checked. At the last visit, the patients were attended by 16 physicians working in 4 different teams. The medical data were recorded by physicians in the computerized system called ARTEMIS in 120 patients and in standard structured forms in 43 patients. The patients notes were checked to see if 9 clinical items were recorded at the first visit (V1), at the visit before last (V2) and at the last visit (V3). The overall completion rate was high at V1 (92.2%) and significantly decreased at follow-up visits (82.6% at V2 and 83.2% at V3). The completion rate was significantly higher in the computerized records than in the standard notes: 95.8% vs 82.2% at V1, 91.9% vs 56.3% at V2 and 91.6% vs 59.7% at V3. During follow-up (V2 vs V1), a significant decrease in the completion rate of 6 items was observed in the standard notes (tobacco use, alcohol consumption, physical activity, compliance to treatment, body weight, manual blood pressure measurement). In the computerized records, only physical activity completion rate decreased. In conclusion, the computer may help to increase the quality of the medical records as reflected by the completion rate of items related to hypertension care.     

Kaposi''s sarcoma-associated herpesvirus in Kikuchi''s disease

Questions of meaning and challenge by illness, i.e., the spiritual dimension of quality of life (QL) traditionally played an important role in anthroposophically oriented medicine and have gained importance in palliative medicine and supportive care. In the context of a research project on QL in patients with advanced cancer, we therefore investigated the psychometric properties of a questionnaire covering spiritual QL issues, with the aim of providing a module for the assessment of cognitive-spiritual QL. PATIENTS AND METHODS: We investigated 89 patients with advanced breast and gastro-intestinal cancer. Construct validity of a modified version of the SELT (Skalen zur Erfassung von Lebensqualit?t bei Tumorkranken), the SELT-M was tested by multitrait scaling analysis. Discriminant and convergent validity were also tested. The EORTC QLQ-C30 was used as a standard for validation. Results showed the SELT-M as feasible in administration. Four of the five SELT-M subscales were internally consistent (Cronbach's Alpha = > 0.7). The subscale on spiritual QL showed higher within than outside subscale correlations for six of its eight items. Association of the SELT-M with the EORTC QLQ-C30 was good for the items and subscales covering the same aspects of QL in both questionnaires: emotional (Spearman r = 0.61), physical functioning (r = -0.54) and fatigue (r = -0.75). In accordance with expectations, there was no association between spiritual QL with any EORTC QLQ-C30 subscales. Self-assessed spiritual QL in the SELT-M corresponded well with interviewer assessments (test for trend accross ordered groups, P = 0.0023). CONCLUSIONS: Overall there is confirming evidence for the hypothesised structure of the SELT-M, especially for the newly developed module on spiritual QL. This module may be used as a module together with other cancer specific QL questionnaires.     

The disintegration of superEBA cement in solutions with adjusted pH and osmolarity

OBJECTIVE: To determine how physicians respond to a request for an expensive, unindicated test. DESIGN: Cross-sectional observational study. SETTING: Four sites of a group-model HMO. PARTICIPANTS: Thirty-nine internist volunteers. INTERVENTION: A standardized patient requesting magnetic resonance imaging (MRI) of the head to rule out multiple sclerosis (MS) was inserted unannounced into physicians' regular schedules. The patient's only complaint was fatigue with no neurologic symptoms. MEASUREMENTS AND MAIN RESULTS: Physicians and standardized patients completed assessments after each visit. Thirty-five (90%) of 39 physicians "had no idea" that the patient they saw was the standardized patient, and the remaining four participants (10%) were only "somewhat suspicious." Three (8%) of the physicians agreed to the MRI at the initial visit, and eight (22%) said they might order an MRI in the future. All doctors who refused the MRI told the patient this was based on lack of a medical indication for the test; seven (19%) also cited the test's expense. Twenty physicians (53%) of 38 agreed to a neurology referral. In response to the standardized patient's concerns, nine physicians (23%) verbalized that MS is scary, and four (10%) asked the patient about their friend's experience with MS. A few physicians appeared to dismiss the patient's concerns, such as by telling the patient they were being "paranoid." CONCLUSIONS: Few physicians agreed to a standardized patient's request for a medically unindicated MRI, but more than half agreed to refer this patient to a specialist. As physicians practice cost-conscious medicine, they may need to focus on good communication to maintain patient satisfaction.     

Patient values: the guide to medical decision making

Physicians are increasingly challenged by issues surrounding medical decision-making for hospitalized patients. Advance directives express a patient's preferences regarding end-of-life care; when available, they should be used to guide medical treatment. Patients who lack decision-making capacity require special consideration to ensure maximal patient participation with appropriate surrogate involvement. An ethics committee consultation may be especially helpful to resolve conflicts that may arise regarding medical treatments. Physicians play a vital role in promoting earlier patient-physician discussions about end-of-life care preferences, increased completion of advance directives, and ongoing education for physicians to improve communication skills.     

Hepatocyte growth factor and fibroblast growth factor 2 are overexpressed after cerulein-induced acute pancreatitis

Competency assessments are a growing function of the consultation-liaison (C-L) psychiatrist. Such consultation requests often mask a variety of psychosocial issues that are a source of frustration to the referring physician responding to the pressures of the changing health care delivery system in the acute care setting. This study identifies the issues and the outcome of psychiatric consultation in these patients. The implications of this burgeoning role for the C-L psychiatrist are also explored.     

Mail consultations in ophthalmology. The Tenth Richard E. Hoover Lecture

BACKGROUND: Although a number of diagnostic and therapeutic methods are available to assist the ophthalmologist, relatively little attention has been given to mail consultations. By this method, a clinical summary and photographs, fluorescein angiograms, ultrasonograms, and/or other relevant materials are mailed to a consultant who then renders an opinion by telephone and/or return mail. MATERIALS AND METHODS: The records of all mail consultations that were sent to the senior author and his colleagues during a 20 year period were reviewed to determine the total number of mail consultations, the reasons for the consultations, and the diagnoses and therapeutic recommendations that were made by the consultant. RESULTS: A total of 1357 mail consultations were received during the 20 year period, with a progressively increasing number of consultations each year. Consultations were received from 757 physicians representing all 50 states in the United States and 32 other countries. Because of the authors' subspecialty in ocular oncology and medical retinal diseases, the majority of the consultations received were related to those topics. In many cases, the initial diagnosis and treatment plan were altered based on our opinion through mail consultation. Based on the material received, the recommendations that we made included observation in 635 cases, enucleation in 152, surgical excision of a lesion in 120, plaque radiotherapy in 102, laser photocoagulation in 81, systemic evaluation in 40, external beam irradiation in 36, fine needle aspiration biopsy in 33, orbital exenteration in 25, chemotherapy in 21, and cryotherapy in 14. CONCLUSION: Although not as ideal as direct patient examination, mail consultation can be an effective method of making or confirming a diagnosis and obtaining a therapeutic opinion. Although the authors have received mail consultations related to ocular oncology, this method may be applicable to other subspecialties in ophthalmology and to general medicine.     

Idiopathic detrusor-urethral dyssynergia in dogs: a retrospective analysis of 22 cases

Physicians make recommendations to their patients on a daily basis regarding tests and procedures. However, no research has evaluated physicians use of similar tests for their own health and well-being. This article reviews a comparison between 55 male physicians and 55 male attorneys of similar age regarding their use of the annual physical examination and routine screening tests. In several areas, the results indicate that physicians do not participate in routine tests and procedures as well as do their legal counterparts. Possible explanations for this physician behavior are included in the discussion segment of the article.     

A dilemma in analysis: issues in the serial measurement of quality of life in patients with advanced lung cancer

Despite the availability of several instruments to evaluate quality of life (QL) over time in patients with lung cancer, barriers in measurement remain. This methodological study used LCSS data (Lung Cancer Symptom Scale, a disease- and site-specific QL measure) to examine analysis methods to quantify QL where data needed for serial evaluation may be missing. Data from two large randomized trials, conducted at 30 centers, of a new combination chemotherapy regimen incorporating a new agent for patients (n = 673) with Stage III and IV non-small cell lung cancer were obtained for this study. QL had been prospectively measured at baseline, day 29, and every six weeks thereafter using the LCSS. For the slope analysis (SA) and area under the curve (AUC) analyses, an adjustment score of zero was used to indicate QL on the day of death (mortality adjustment) and each subsequent day until the end of the assessment period. Significant differences in QL, symptom scores and known prognostic factors at baseline were found in the attrition group. SA and AUC analysis allowed inclusion of 581 patients, giving an adequacy rate of 86%. By using a mortality adjustment, an additional 45 patients were included, increasing the inclusion rate to 93%. With the use of the mortality adjustment, QL was shown to decline over the interval, as opposed to rise if the adjustment had not been performed. The conclusions of the study were: (1) analysis for serial data using SA and AUC provides useful, but differing information; (2) when attrition (caused by death) is a factor, a mortality adjustment presented a more accurate assessment of QL as an endpoint; (3) more frequent evaluations of QL will capture rapid changes in patient status and reduce the attrition bias; (4) all patients should be followed until they die; and (5) QL should be given full consideration as a primary endpoint separate from survival.