Communicating with dying patients within the spectrum of medical care from terminal diagnosis to death.

BACKGROUND: Efforts to improve communication between physicians and dying patients have been unsuccessful, and guidelines for improving patient-physician communication about end-of-life care are based primarily on expert opinion. This study assessed which aspects of communication between patients and physicians are important in end-of-life care. METHODS: Twenty focus groups were held with 137 individuals, including patients with chronic and terminal illnesses, family members, health care professionals from hospice or acute care settings, and physicians with expertise in end-of-life care. Focus group analyses determined domains of physician skill at end-of-life care. Communication with patients was identified as one of the most important domains. Analyses of components important in communicating with dying patients and their families were performed. RESULTS: The following 6 areas were of central importance in communicating with dying patients: talking with patients in an honest and straightforward way, being willing to talk about dying, giving bad news in a sensitive way, listening to patients, encouraging questions from patients, and being sensitive to when patients are ready to talk about death. Within these components, subthemes emerged that provide guidelines for physicians and educators. Dying patients also identified the need to achieve a balance between being honest and straightforward and not discouraging hope. CONCLUSIONS: Several areas emerged for physicians to focus their attention on when communicating with dying patients. These findings provide guidance in how to improve this communication. They also highlight the need to approach communication about end-of-life care as a spectrum that requires attention from the time of a terminal diagnosis through death.

Understanding physicians' skills at providing end-of-life care perspectives of patients, families, and health care workers.

BACKGROUND: A framework for understanding and evaluating physicians' skills at providing end of life care from the perspectives of patients, families, and health care workers will promote better quality of care at the end of life. OBJECTIVE: To develop a comprehensive understanding of the factors contributing to the quality of physicians' care for dying patients. DESIGN: Qualitative study using focus groups and content analysis based on grounded theory. SETTING: Seattle, Washington. PARTICIPANTS: Eleven focus groups of patients with chronic obstructive pulmonary disease, AIDS, or cancer (79 patients); 3 groups of family members who had a loved one die of chronic disease (20 family members); 4 groups of nurses and social workers from hospice or acute care settings (27 health care workers); and 2 groups of physicians with expertise in end-of-life care (11 physicians). RESULTS: We identified 12 domains of physicians' skills at providing end-of-life care: accessibility and continuity; team coordination and communication; communication with patients; patient education; inclusion and recognition of the family; competence; pain and symptom management; emotional support, personalization; attention to patient values; respect and humility; and support of patient decision making. within these domains, we identified 55 specific components of physicians' skills. Domains identified most frequently by patients and families were emotional support and communication with patients. Patients with the 3 disease groups, families, and health care workers identified all 12 domains. Investigators used transcript analyses to construct a conceptual model of physicians' skills at providing end-of-life care that grouped domains into 5 categories. CONCLUSIONS: The 12 domains encompass the major aspects of physicians' skills at providing high-quality end-of-life care from the perspectives of patients, their families, and health care workers, and provide a new framework for understanding, evaluating, and teaching these skills. Our findings should focus physicians, physician-educators, and researchers on communication, emotional support, and accessibility to improve the quality of end-of-life care.

Insights from outstanding rural internal medicine residency rotations at the University of Washington.

PURPOSE: Despite being well suited to provide the breadth of care needed in rural areas, few general internists become rural physicians. Little formal rural residency training is available and no formal curricula exist. For over 25 years the University of Washington School of Medicine has provided elective WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) rural residency rotations to expose residents to the rewards and challenges of rural practice. This study identified the characteristics of outstanding rural residency rotations. METHOD: The key preceptors at three outstanding rural residency sites were interviewed about their experiences, teaching strategies, and opinions about curriculum. Their responses were categorized. Seven university-based residents and eight training at WWAMI sites recorded and rated the value of over 1,500 learning encounters. RESULTS: The preceptors agreed that outstanding rotations were led by enthusiastic preceptors who served as role models for excellence. These preceptors provided residents with meaningful responsibilities and emphasized independent decision making based on the history and physical examination. They stressed supervised independence and self-directed learning with frequent structured feedback for residents. The residents rated the learning value of patient encounters in rural locations significantly higher than that of those in university clinics. CONCLUSIONS: Exceptional rural residency experiences involve excellent role models who provide meaningful responsibility and emphasize core skills using a learner-centered approach. Rural training experiences should be supported, and the suggestions of outstanding preceptors should be used to develop and disseminate a curriculum that will better prepare residents for rural practice.

Participation in enrichment programs and its effect on interview scores of applicants to the University of Washington School of Medicine.

Enrichment programs for underrepresented-minority (URM) and disadvantaged students provide a variety of motivational, academic, and research opportunities. Many enrichment programs take place in medical schools, where one might expect the students to pick up skills and knowledge that could give them a competitive advantage during their medical school admission interviews. To test this, the authors surveyed the 227 URM students who were interviewed at the University of Washington School of Medicine in 1993, 1994, and 1995, dividing them into two groups: 97 students who had participated in enrichment programs and 130 students who had not. The authors compared the interview scores of the two groups. Participation in an enrichment program was not associated with better interview scores. Being a woman and having strong MCAT verbal reasoning scores were the only variables that had statistical significance for the prediction equation of the interview score.

Teaching compassion and respect. Attending physicians' responses to problematic behaviors.

OBJECTIVE: To describe how and why attending physicians respond to learner behaviors that indicate negative attitudes toward patients. SETTING: Inpatient general internal medicine service of a university-affiliated public hospital. PARTICIPANTS: Four ward teams, each including an attending physician, a senior medicine resident, two interns, and up to three medical students. DESIGN: Teams were studied using participant observation of rounds (160 hours); in-depth semistructured interviews (n = 23); a structured task involving thinking aloud (n = 4, attending physicians); and patient chart review. Codes, themes, and hypotheses were identified from transcripts and field notes, and iteratively tested by blinded within-case and cross-case comparisons. MAIN RESULTS: Attending physicians identified three categories of potentially problematic behaviors: showing disrespect for patients, cutting corners, and outright hostility or rudeness. Attending physicians were rarely observed to respond to these problematic behaviors. When they did, they favored passive nonverbal gestures such as rigid posture, failing to smile, or remaining silent. Verbal responses included three techniques that avoided blaming learners: humor, referring to learners' self-interest, and medicalizing interpersonal issues. Attending physicians did not explicitly discuss attitudes, refer to moral or professional norms, "lay down the law," or call attention to their modeling, and rarely gave behavior-specific feedback. Reasons for not responding included lack of opportunity to observe interactions, sympathy for learner stress, and the unpleasantness, perceived ineffectiveness, and lack of professional reward for giving negative feedback. CONCLUSIONS: Because of uncertainty about appropriateness and effectiveness, attending physicians were reluctant to respond to perceived disrespect, uncaring, or hostility toward patients by members of their medical team. They tended to avoid, rationalize, or medicalize these behaviors, and to respond in ways that avoided moral language, did not address underlying attitudes, and left room for face-saving reinterpretations. Although these oblique techniques are sympathetically motivated, learners in stressful clinical environments may misinterpret, undervalue, or entirely fail to notice such subtle feedback.

Enrichment programs for undergraduate college students intended to increase the representation of minorities in medicine.

The authors reviewed the literature published from 1966 to 1996 to identify enrichment programs for underrepresented minority college students sponsored by medical schools and affiliated programs, finding 20 such programs. The programs reported in the literature underestimate the number and variety of programs known to exist by about two thirds. The authors categorized the reported programs according to the types of components they contained. Most programs contained more than one component type. Eighteen of the programs had an academic enrichment component. Thirteen programs included components focused on preparation for the admission process. Mentoring activities were a component of only four of the programs. Eighteen of the 20 programs were evaluated in the literature. The largest focus of evaluation activities was the success of program participants entering medical school. While the medical school matriculation rate was quite high, these results were difficult to interpret as the studies did not use control groups. The evaluations could not demonstrate, therefore, that the programs were responsible for increased admission of minorities to medical schools. Relatively few studies measured the immediate effects of the programs' efforts. Further, there was even less evidence of which program components in particular were effective. A more public and energetic discussion of these programs in the medical education literature is essential. In a political and social environment that calls for accountability, programs must be able to clearly and truthfully declare what they have accomplished. Without this type of public discussion, enrichment programs for underrepresented minorities may continue to appear to be worthwhile endeavors, but lacking solid support and foundation and vulnerable to losing funding.

Precollege enrichment programs intended to increase the representation of minorities in medicine.

The authors reviewed the literature published from 1966 to 1996 to identify enrichment programs for underrepresented minority precollege students sponsored by medical schools and affiliated programs, finding 19 articles describing 27 programs. The authors categorized the reported programs according to the components they contained. Most programs contained more than one component type. Twenty-four programs had an academic enhancement component. Two thirds had a motivational component to encourage students to consider medical and other health careers. Two programs set up mentoring relationship between students and health professionals. There were four research apprenticeships and three academic partnerships between medical schools and local school districts. Twelve of the 27 programs were evaluated in the literature. Eight evaluations focused on identifying the numbers of students who continued their education into college and professional schools. Five programs reported participant satisfaction or identified other short-term outcomes such as gains on standardized tests. While the percentage of participants completing college and entering health care careers is impressive, the authors do not believe that the educational success of participants can be attributed to involvement in these programs. The authors recommend ways to improve the quality and interpretability of enrichment program evaluations. Evaluators should adopt common terminology for activities and outcomes. Participants' economic and educational disadvantages should be described. Programs' theoretical underpinnings should be identified and related to evaluation. Measures should include immediate effects as well as long-term outcomes. Where possible, data from comparison groups should be reported to support conclusions. Adequate funding needs to be available to design and complete reasonable evaluations.

History-taking and preventive medicine skills among primary care physicians: an assessment using standardized patients.

BACKGROUND: The ability of primary care physicians to obtain important clinical information in initial encounters with new patients is a core competency that has received little attention in previous studies. This paper describes the history-taking and preventive screening skills of practicing primary care physicians in initial interactions with ambulatory patients, as determined by a large panel of standardized patients. METHODS: Standardized patient cases with diverse presentations were developed and used to assess the clinical skills of 134 primary care physicians from five Northwest states. Scoring categories for each case identified the percentage and content of essential history items and preventive screening items performed. Physicians' scores were compared by training and practice characteristics. RESULTS: Physicians asked 59% of essential history items. They frequently obtained appropriate information about presenting symptoms and medications, but they often missed important information about related symptoms and medical history. Physicians frequently screened for smoking and alcohol use, but rarely asked about recreational drug use. Although board-certified general internists performed more comprehensive histories than board-certified family practitioners in the same amount of time, both groups of providers missed a large number of items that should have been influential in developing diagnostic and treatment plans. CONCLUSIONS: Primary care physicians may miss important patient information in their initial interactions with patients. Medical intake questionnaires or other approaches should be considered to ensure that more complete and accurate information is available to guide diagnostic and treatment plans.

A study of medical students' specialty-choice pathways: trying on possible selves.

PURPOSE: To describe the decision-making processes reported by graduating medical students in choosing primary care (PC) or non-primary-care (NPC) specialties. METHOD: Members of the University of Washington School of Medicine's graduating class of 1995 were invited to participate in focus groups. Six specialty-choice pathways were defined based on a previously administered survey of recalled preferences at matriculation and stated choice at the time of the National Resident Matching Program. Students were assigned to focus groups based on specialty-choice pathway. Transcribed discussions and summaries were thematically coded and analyzed using grounded theory and quantitative comparisons. RESULTS: Of 157 students, 140 (89%) completed the initial survey, and 133 (85%) provided enough information to be classified by pathway. In all, 47 students participated in the focus group discussions. The PC students cited PC orientation, diversity of patients and activities, role models and mentors, interaction with patients, and overall medical school culture as having influenced their choice. The NPC students cited lifestyle, controllable hours, opportunities to do procedures, therapeutic urgency and effect, active tempo, exciting settings, and intellectual challenge. Role models influenced PC career choice much more than NPC career choice, and often served to refute negative stereotypes. The sense of personal fit between themselves and specialties was important to the students in all groups, but differed in emphasis according to career-choice pathways. Those whose preferences did not change experienced a confirmation of pre-existing beliefs, while those who switched specialty areas developed a sense of fit through the inclusion or elimination of different practice aspects. Those who switched specialty areas reported more negative influences and misunderstanding of their initially preferred specialties. CONCLUSION: The process of specialty choice can be described usefully as a socially constructed process of "trying on possible selves" (i.e., projecting oneself into hypothetical career and personal roles). This may explain role models' exceptional influence in disproving negative stereotypes. Medical students' choices can best be facilitated by recognizing their needs to gain knowledge not only about specialty content, but also about practitioners' lives and the students' own present and possible selves.

HIV risk screening in the primary care setting. Assessment of physicians skills.

OBJECTIVE: To assess the content and extent of HIV risk assessment by primary care physicians across a diverse panel of patients with unidentified HIV risk behaviors. DESIGN: Standardized patient examination to assess primary care physicians' skills at identifying and managing HIV infection and overall clinical skills. In a day of testing, physicians saw 13-16 standardized patients (SPs) with diverse case presentations. In analyses presented here, physician performance was examined with nine SPs who had unidentified risks for HIV, which they offered if asked. SETTING: An academic clinic. PARTICIPANTS: We randomly selected 134 paid volunteers (general internists and family/general practitioners) after stratifying by specialty, experience caring for patients with HIV infection, and year of medical school graduation. MEASUREMENTS AND MAIN RESULTS: Performance at initiating HIV risk screening and identifying patients' HIV risk behaviors were the main outcome measures. Physicians performed variably at HIV risk screening with different patients and across different HIV risk screening topics. Although physicians initiated screening with 60% of patients, they identified only 49% of risk behaviors and included HIV in the differential diagnosis for less than half of at-risk patients. Physicians performed better with cases in which there was a higher probability of HIV infection based on symptoms, but often did not screen at-risk patients without obvious symptoms suggestive of HIV. Board-certified general internists initiated screening and identified risk behaviors with more patients than board-certified family practitioners. Medical school graduation year also influenced performance. CONCLUSIONS: Our data suggest that primary care physicians do not routinely perform HIV risk assessments with patients who have risk behaviors for HIV infection. Methods are needed to develop, standardize, and disseminate better screening techniques to identify patients with or at risk of developing HIV infection, such as written HIV risk screening questions for use in medical intake forms.

An early preceptorship and medical students' beliefs, values, and career choices.

BACKGROUND AND OBJECTIVES: Curriculum influence on career choice is difficult to determine. In this study we explored the impact of a summer rural/underserved preceptorship on the residency choices of participants and on the beliefs and attitudes of participating students about rural underserved primary care practices. METHODS: Two data sets are used to examine the Rural/Underserved Opportunities Program (R/UOP). Matriculation and residency selection information is analyzed to compare R/UOP participants with nonparticipants. Second, a survey eliciting beliefs and attitudes about various career choices was given to participants before and after the experience and to a sample of non-participating classmates matched for age, race, and ethnicity. RESULTS: At matriculation, R/UOP participants gave higher rankings to primary care specialties as possible career choices. They were more likely to be matched in a primary care residency than nonparticipants. R/UOP participants expressed belief in more differences between urban and rural practice than did nonparticipants. They maintained their higher attitudes towards rural practice. CONCLUSIONS: R/UOP supports preexisting beliefs and positive attitudes towards rural underserved primary care careers. Participating students do not have large differences at entry into medical school. They are more likely to select primary care residencies, compared with nonparticipants.

Faculty development for ambulatory care education.

Faculty play an important role in the delivery of quality instruction in the ambulatory setting. As medical schools and residency programs move more clinical training to ambulatory care settings, more faculty must be recruited and trained. Medical educators have attempted to prepare faculty to teach in ambulatory care settings by conducting faculty development programs. This study documents the current practices of a sample of 14 peer-nominated medical educators who conduct this type of faculty development program. The authors conducted telephone interviews to learn what these educators taught, how they conducted and evaluated their programs, and the theoretical framework guiding their selection of program content and format. Results show that these faculty development programs were delivered almost exclusively in the workshop format, and that there was remarkable similarity in the topics and strategies used. Evaluation was generally limited to satisfaction ratings. Based on the results of this study, the authors recommend that faculty development programs that now emphasize the teaching encounter itself should give equal emphasis to (1) the importance of pre-instructional planning; (2) teaching faculty how to employ post-instructional techniques such as reflection; and (3) training learners and clinic staff to collaborate with faculty in the learning process.

Role models' perceptions of themselves and their influence on students' specialty choices.

PURPOSE: To examine the perceptions of faculty role models to learn whether their perceptions of role models' behaviors are congruent with those of their students. METHOD: In 1996 a survey was mailed to 210 student-identified faculty role models at the University of Washington School of Medicine and the University of North Carolina at Chapel Hill School of Medicine. The nominees were asked to rate to what extent each of 32 student-identified role model characteristics was representative of their behavior. They were then asked to rank order the characteristics they felt were most important to model for students. The role models were also asked to rate how much influence they perceived themselves to have on their students' specialty choices. A final, open-ended question inquired about the single characteristics they modeled to students that most influenced the students' specialty choices. The role models' specialties were grouped as either primary care (PC) or non-primary care (NPC). Data were analyzed with several statistical methods. RESULTS: Of the 210 mailed surveys, a total of 177 were returned, for a response rate of 84%. The role models perceived their behaviors much like their students did; the role models' self-ratings were generally high for all of the student-defined characteristics. Although clinical reasoning was considered the most important characteristic to model for students, the role models also believed that enthusiasm and love for their work were the characteristics that most influenced their students' specialty choices. Few differences were found between the PC and the NPC role models. CONCLUSION: The role models in this study agreed with their students about what is important to model. They did not intentionally try to recruit students to join their specialties but felt that demonstrating enthusiasm and a sincere love for what they did has a strong influence toward this end.

Feasibility of hospital-based use of peer ratings to evaluate the performances of practicing physicians.

PURPOSE: To address the feasibility of obtaining reliable evaluations of individual physicians from peer ratings undertaken at diverse hospitals. METHOD: Eleven hospitals in diverse locations in the United States were recruited to participate. With the aid of the hospitals' medical directors, up to 40 board-certified internists with admitting privileges were recruited per hospital. Participating physicians provided demographic data about themselves and nominated physician-associates to do peer ratings. Between April 1993 and January 1994, the physicians were rated by their peers, who received a single mailing with no follow-up. The raters used a nine-point Likert scale for 11 cognitive and noncognitive categories. Administrative procedures were coordinated from the American Board of Internal Medicine. Chi-square, Student's t-test, and factor analysis using varimax rotation were used to analyze the results. RESULTS: Of the 4,139 questionnaires that were mailed to peer raters, 3,005 (73%) were returned. Of the 228 physicians who were rated, 187 received ten or more usable ratings, which were used for further analysis. The findings confirmed the results of previous research. The highest mean rating was for the category of integrity, and the lowest was for the category of psychosocial aspects of care. Ten to 11 responses per physician were necessary to achieve a generalizability coefficient of .7. Nearly 90% of the variance in the ratings was accounted for by two factors, one representing cognitive and clinical management skills and the other, humanistic qualities. For 16 physicians (9%), the ratngs of overall clinical skills were less than 7 on a scale from 1 (low) to 9 (high); their ratings for all individual cognitive and noncognitive categories were below the ratings of the other physicians. CONCLUSION: The peer raters' response rate and the analysis of the ratings suggest that the rating process is acceptable to physicians and that it is feasible to obtain reliable, multidimensional peer evaluations of individual physicians practicing in diverse clinical settings.

Patient report of HIV risk screening by primary care physicians.

Our objectives were to (1) assess primary care physicians' performance at screening patients for HIV risks using patient report; (2) compare patient recall concerning screening with physician report; and (3) compare HIV risk screening with general preventive health screening. Up to 20 patients from 126 physicians' practices anonymously completed 1,820 questionnaires. Questionnaires assessed screening from physicians about HIV risks and general preventive health care. Two scales were developed to measure comprehensiveness of screening. Based on patient recall, physicians performed poorly in HIV risk screening. On an HIV risk-screening scale, patients were screened concerning 11% of items assessed. In comparison, patients recalled screening concerning 75% of general prevention items assessed. Patients with acknowledged HIV risk factors and younger patients were screened more for HIV risk, but many patients with risks were still missed. Physicians' estimates of their screening were relatively concordant with patient report in general prevention areas but were discordant with patient recall of HIV risk screening; physicians estimated considerably more screening than their patients recalled. Female physicians performed better than male physicians in both HIV risk screening and general preventive health screening; physicians with more HIV experience performed better at HIV risk screening. HIV risk screening in the primary care setting remains inadequate. Comparable attention to that given to general prevention by primary care physicians is needed in screening patients for HIV risk behaviors.

Ability of primary care physicians to recognize physical findings associated with HIV infection.

OBJECTIVE: To assess the ability of primary care physicians to identify physical findings associated with human immunodeficiency virus (HIV) infection. DESIGN: Standardized patient examination. PARTICIPANTS: A total of 134 general internists and family practitioners were randomly selected after stratifying by year of medical school graduation, specialty, and experience caring for patients with HIV infection. MAIN OUTCOME MEASURES: Recognition of physical findings of Kaposi's sarcoma, oral hairy leukoplakia, and diffuse lymphadenopathy. RESULTS: Despite being directed by presenting histories to sites of prominent physical abnormalities, only 23 (25.8%) of 89 physicians evaluating a patient with Kaposi's sarcoma and 22 (22.7%) of 97 physicians evaluating a patient with oral hairy leukoplakia detected and correctly diagnosed the abnormalities. Twenty-three (17%) of 133 physicians detected diffuse lymphadenopathy in a patient complaining of fatigue, fever, and arthralgias. Physicians with the most experience treating patients with HIV infection more frequently identified oral hairy leukoplakia, but HIV experience did not influence identification of Kaposi's sarcoma or detection of lymphadenopathy. There were no differences between general internists and family practitioners or among physicians by year of medical school graduation in identifying the three physical findings associated with HIV infection. CONCLUSIONS: Primary care physicians may frequently miss important physical findings related to HIV infection during patient examinations.

Do primary care physicians screen patients about alcohol intake using the CAGE questions?

The performances of 134 primary care physicians at initial screening about alcohol use and screening with the CAGE questions were assessed using 17 standardized patients. For three-fourths of the standardized patients, more than 50% of the physicians asked an initial alcohol screening question. However, use of the CAGE questions with six patients who reported drinking more than one drink per day was less consistent; for most of these patients, few physicians asked any CAGE questions. Fewer than 50% of the physicians included alcohol abuse in the differential diagnosis for three of four patients who drank four or more drinks per day. Methods are needed to incorporate the CAGE questions into primary care practices in a more systematic manner.

Physicians' ability to provide initial primary care to an HIV-infected patient.

BACKGROUND: Primary care physicians are providing care for an increasing number of persons infected with the human immunodeficiency virus (HIV). This study assesses the ability of primary care physicians to provide initial care for a patient with recently diagnosed HIV infection. METHODS: A standardized patient (SP) was trained to portray an asymptomatic person with HIV infection seeking a primary care physician. Physicians took a medical history and counseled the SP; their performances were assessed by the SP and through a brief written examination. In addition, physicians distributed questionnaires to HIV-infected patients in their practices to assess actual performance. The study participants consisted of 121 primary care physicians. RESULTS: A minority of physicians recommended standard primary care screening tests and vaccinations, including viral hepatitis screening (35%), syphilis serologic testing (32%), and pneumococcal vaccination (23%). While most physicians (87%) indicated they would obtain CD4 cell counts, only 50% indicated they would start appropriate Pneumocystis carinii pneumonia prophylaxis. Although this patient presented documentation of a positive tuberculin skin test and no prior therapy for tuberculosis, only 53% of the physicians recommended prophylactic isoniazid. While 75% of the physicians asked this SP about condom use, number of sexual partners, or contact with previous sexual partners. Physicians with the most HIV experience were more likely to recommended P carinii pneumonia prophylaxis, coinfection screening, pneumococcal vaccination, and isoniazid prophylactic therapy. However, physicians' HIV experience was not associated with assessing this SP's risk of infecting others or with counseling regarding condom use. Questionnaires distributed to HIV-infected patients of these physicians generally confirmed these findings. CONCLUSIONS: Basic HIV preventive and primary care may not be adequately performed by many primary care physicians. Physicians' HIV experience was associated with better performance of HIV primary care tasks, but not with screening and counseling concerning the spread of HIV infection.

Ability of primary care physicians to diagnose and manage Pneumocystis carinii pneumonia.

This study assesses the ability of primary care physicians to diagnose and manage Pneumocystis carinii pneumonia (PCP) in a standardized patient (SP) with unidentified HIV infection. One hundred thirty-four primary care physicians from five Northwest states saw an SP with unidentified HIV infection who presented with symptoms, chest radiograph, and arterial blood gas results classic for PCP. Seventy-seven percent of the physicians included PCP in their differential diagnoses and 71% identified the SP's HIV risk. However, only a minority of the physicians indicated that they would initiate an appropriate diagnostic evaluation or appropriate therapy: 47% ordered a diagnostic test for PCP, 31% initiated an antibiotic appropriate for PCP, and 12% initiated an adequate dose of trimethoprim - sulfamethoxazole. Only 6% of the physicians initiated adjunctive prednisone therapy, even though prednisone was indicated because of the blood gas result. These findings suggest significant delay in diagnosis and treatment had these physicians been treating an actual patient with PCP.