Thrombolytics in infectious endocarditis associated myocardial infarction.

The use of thrombolytics in the management of acute myocardial infarction in eligible patients is the accepted standard of practice. We present the case of an embolic myocardial infarction in the setting of acute infectious endocarditis, treated with thrombolytics, resulting in a massive intracerebral hemorrhage and the patient's death. Historical and current literature has shown a consistent and significant incidence of concurrent intracerebral mycotic aneurysms in the setting of infectious endocarditis. Despite this, a literature review of contraindications to the use of thrombolytics rarely recognizes endocarditis as a contraindication. It is imperative that the etiology for myocardial infarction be identified; if contraindications to thrombolytic treatment exist, alternative therapeutic interventions must be pursued. This case highlights the importance of the correct etiologic diagnosis of myocardial ischemia, and increases the awareness of the significant risks of intracerebral hemorrhage associated with the use of thrombolytics in the setting of endocarditis.

Substance-impaired physicians probationary and voluntary treatment programs compared.

We compared the characteristics and treatment outcomes of substance-impaired physicians monitored by two different programs in Oregon: a probationary program administered by the Oregon Board of Medical Examiners and the confidential, voluntary Diversion Program for Health Professionals. Demographic, substance use, and treatment outcome variables were obtained by a retrospective medical record review from 41 physicians monitored by the Oregon board and 56 physicians monitored by the diversion program during a 3-year study period. Compared with physicians monitored by the Oregon board, physicians in the diversion program were younger, more likely to be in training programs and less likely to be in hospital-based practice settings, more often reported by immediate rather than third-party contacts, more likely to choose in-state inpatient treatment than out-of-state treatment, and less likely to have concurrent mental illness diagnoses (P < .05 for all comparisons). Short-term relapse rates did not differ statistically between the groups (22.0% for the Oregon board group, 14.3% for the diversion program group). The higher number of younger physicians and physicians in training and tendency toward increased reporting by immediate contacts in the diversion program suggested earlier intervention than in the Oregon board group.

Alcohol and other substance abuse and impairment among physicians in residency training.

Substance abuse and impairment are serious societal problems. Physicians have historically had high rates of substance abuse, which has been viewed as an occupational hazard. Most authorities agree that the rate of alcoholism among practicing physicians is similar to that among control populations and that the rates of other substance abuse are greater, although some studies have shown no difference. Data about substance abuse among residents in training are limited but suggest that the use of benzodiazopines is greater than that among age-matched peers, whereas the use of alcohol is similar between the two groups. Medical institutions, including those with teaching programs, have legal and ethical responsibilities concerning substance abuse among current and future physicians. Many training programs, however, do not provide educational programs on this subject, do not have faculty trained in substance abuse medicine, and do not have a formal system to address the problem of residents who are suspected or known to be substance abusers. This position paper examines the extent of substance abuse, including alcohol abuse, among physicians in residency training. It outlines approaches to the problem and delineates responsibilities of institutions and residency program directors. Recommendations are made to establish an informational program and a clearly defined, organized process to address the problems of substance abuse among residents. Careful and humane approaches can be used to identify and treat residents with substance abuse problems and thus allowing them to complete their training as competent and drug-free professionals.

Predictors of clinical performance among internal medicine residents.

OBJECTIVE: To determine whether personal characteristics influence residents' psychological states during training and to evaluate the relative importance of personal characteristics and psychological states in predicting clinical performance. DESIGN: Cohort study utilizing prospective, serial surveys of emotions (anxiety, depression, competence) and attitudes (satisfaction with the decision to become a physician) among two classes of internal medicine residents during all years of their training. Subjects completed a socio-demographic survey at the conclusion of training, and faculty-assigned clinical ranks and examination scores were used to rate their clinical performances. MAIN RESULTS: Personal characteristics had a stronger relationship to psychological states during the first training year than in subsequent years. The highest association was found for depression, for which 25% of the variation was accounted for by personal characteristics. The combination of personal characteristics and psychological states explained 48% of the variation in clinical ranks and 38% of the variation in American Board of Internal Medicine certifying examination scores. CONCLUSION: There are recognizable relationships among the personal characteristics of residents, their psychologic states during training, and their clinical performances. These results should be helpful to program directors and faculty in identifying potentially weak residents and avoiding pitfalls when working with troubled residents.

A prospective study of internal medicine residents' emotions and attitudes throughout their training.

To evaluate whether the negative emotions and attitudes that residents develop during internship continue throughout the remaining years of their residency, the authors undertook a four-year prospective study of two classes of internal medicine residents who completed their training in 1985 and 1986 in a residency program based at the Oregon Health Sciences University. Every two to three months over all three years of training, the residents indicated on Likert-type scales their levels of agreement with questions about their career satisfaction and emotional states, and the satisfying and dissatisfying aspects of their residency experiences. Between the internship and the end of their residencies, the physicians indicated significant improvements in their emotions and attitudes. Those experiences identified as satisfying continued to be so, whereas those considered dissatisfying became less so. Although more research of other classes of residents is needed, the findings suggest that while internal medicine internships may be dysphoric, the residents' emotional states and attitudes tend to normalize during the remainder of the residency.

The doctor-patient relationship during medical internship: the evolution of dissatisfaction.

We prospectively examined perceptions of the doctor-patient relationship among interns in two different internal medicine training programs five times during the internship year. All 59 interns in the University of California, Irvine-Long Beach and the Oregon Health Sciences University Medical Programs participated in the study during the 1982-83 internship year. We serially administered a questionnaire that contained four major items: (1) a choice of one of six empirically developed role paradigms of the doctor-patient relationship; (2) a checklist of positive and negative aspects of internship; (3) a measure of level of satisfaction with the decision to become a physician; and (4) a rating list of mood descriptors. The six role paradigms portrayed a variety of positive and negative aspects of the doctor-patient relationship. At the beginning of the year, the interns were quite positive about the doctor-patient relationship and preferentially endorsed collegial models. As the year progressed, they endorsed significantly fewer positive and more negative models (P less than 0.001). Most respondents endorsed two models, one positive: "expert resource (doctor)--active cooperative participant (patient)" and one negative: "clerk, paperwork processor (doctor)--subscriber, seeker of eligibility (patient)." By the end of the year approximately half of the interns endorsed a positive and half a negative model. Interns selecting a negative model of the doctor-patient relationship identified more negative and fewer positive aspects of internship than those selecting a positive model. Specifically, they significantly more often (P less than 0.001) identified too much paper work and coping with difficult patients as negative aspects of internship.(ABSTRACT TRUNCATED AT 250 WORDS)

Hematologic effects of acute and chronic alcohol abuse.

Alcoholism affects 3 to 10 per cent of the American population. Alcohol is toxic to all organ systems. This article summarizes current information about the hematologic sequelae of alcohol abuse. A brief summary of ethanol-related metabolic events is followed by discussion of specific disorders of erythrocytes, leukocytes, platelets, and the immune apparatus.

The internship--a prospective investigation of emotions and attitudes.

In a prospective survey for changes in emotions and attitudes of all medical interns of The Oregon Health Sciences University (N = 22) at six intervals during the 1982-1983 academic year, both positive and negative emotional changes were noted. Satisfaction with the decision to become a physician decreased during the period, a change that correlated directly with depression and fatigue and inversely with excitement and importance.