Stress, Burnout and Coping among Emergency Physicians at a Major Hospital in Kingston, Jamaica.

OBJECTIVES: The study examined the prevalence of stress, burnout, and coping, and the relationship between these variables among emergency physicians at a teaching hospital in Kingston, Jamaica. METHODS: Thirty out of 41 physicians in the Emergency Department completed the Maslach Burnout Inventory, Perceived Stress Scale, Ways of Coping Questionnaire, and a background questionnaire. Descriptive statistical analyses were conducted. RESULTS: Fifty per cent of study participants scored highly on emotional exhaustion; the scores of 53.3% also indicated that they were highly stressed. Stress correlated significantly with the emotional exhaustion and depersonalization components of burnout. Depersonalization was significantly correlated with two coping strategies: escape-avoidance and accepting responsibility; emotional exhaustion was also significantly correlated with escape-avoidance. CONCLUSION: Emergency physicians at the hospital scored high on stress and components of burnout. Interventions aimed at reducing the occupational contributors to stress and improving levels of coping will reduce the risk of burnout and enhance psychological well-being among emergency physicians.

The repeatability of three methods for measuring prospective patients' values in the context of treatment choice for end-stage renal disease.

In the context of the choice of treatment for end-stage renal disease (ESRD), three approaches to value assessment were examined for their repeatability over time within subjects. If formal decision analyses are to be used to advise patients about treatment choice, then repeatable value assessment methods, an essential component of such analyses, are needed. The methods assessed were standard gamble (SG), time trade-off (TTO), and visual analogue (VA). Sixty-six nephrology clinic patients were interviewed on two occasions, 10 days apart, by one of two interviewers. An information session was conducted 1 week before the first interview. Subjects were taught about the treatments using an information package developed expressly for the study and a video produced by a pharmaceutical company for use in this decision context. Patients differed widely in the values provided for the various treatments of ESRD, with responses that ranged across the entire scale (0 to 100). The repeatability of the three methods was poor, with the coefficients of repeatability (95% range of differences from one occasion to the next) observed as +/- 27.4 for SG, +/- 38.4 for TTO, and +/- 36.5 for VA. When subsets defined by characteristics that may have improved the repeatability were analyzed, the magnitude of the error did not vary substantially. The poor repeatability of these methods raises questions about their use for decision analyses applied to the individual context.

A physician-centred intervention to shorten hospital stay: a pilot study.

BACKGROUND: Studies of length of stay (LOS) in hospital usually focus on physician-independent factors. In this study, the authors identified physician-dependent factors and tested an intervention aimed at them to determine its effect on LOS. METHODS: A prospective comparison of LOS on 2 general medical wards in a tertiary care teaching hospital before and after the intervention. The pre-intervention (control) period and the intervention period were each 4 weeks. The intervention consisted of a checklist for planning management and discharge. RESULTS: Overall, the mean LOS was shorter during the intervention period than during the control period, but the difference was not statistically significant (12.0 and 14.4 days respectively, p = 0.13). The difference was significant on ward A (11.0 v. 14.7 days respectively, p = 0.02) but not on ward B (13.0 and 14.0 days respectively, p = 0.90). INTERPRETATION: An intervention at the level of the admitting physician may help to shorten LOS on a general medical ward.

Patients' perceptions of their experiences with ESRD and hemodialysis treatment.

A grounded theory methodology was used to explore patients' experiences with end-stage renal disease (ESRD) and hemodialysis. The emerging theory suggests that a "new sense of self" is an emotional/psychological state that fluctuates with the evolving meanings of illness and treatment and perceived quality of supports. The findings indicate that when confronted with this new way of being in the world, the individual becomes cognizant of an uncertain future, continued dependence on life-sustaining technology and the expertise of health care providers, and the demands on and sacrifices incurred by significant others. All aspects of patients' experiences with ESRD and hemodialysis treatment must be considered if health care providers are to facilitate positive health outcomes.

Content of a decision analysis for treatment choice in end-stage renal disease: who should be consulted?

For an illness whose treatment options lead to similar survival, quality-of-life issues determine the choice. If the patient has not yet experienced the treatments, then the information provided regarding the options plays a crucial role in the patient's choice. The authors interviewed 43 people who are intimately involved with the treatments for end-stage renal disease (ESRD) (ten physicians, 11 nurses, and 22 patients) with a view to determining what information needs to be considered when choosing between the various treatment options for this illness. They compared the three groups based on the items obtained from the interviews to determine whether the inclusion of patients in the process changed the content of the treatment descriptions. They were also interested in determining whether the use of the frequency with which an item is mentioned in the interviews is a valid measure of its relative importance to other items. 1,269 relevant items were obtained from the interviews and categorized into 51 areas of concern (subject domains). The health professionals (physicians and nurses) were found to have mentioned seven subject domains more often than the patients, and no domain was mentioned more often by the patients than by the health professionals. The frequency that an item was mentioned was correlated (r = 0.55) with direct measures of its importance. These results imply that careful consultation with health professionals to determine the content of a decision analysis or informational materials that address treatment choice is sufficient to address patient concerns and that items can be chosen for inclusion based on the relative frequencies with which they are mentioned.

A randomized clinical trial of negative pressure ventilation in severe chronic obstructive pulmonary disease: design and methods.

This report documents the design and methods of a randomized clinical trial designed to test the effectiveness of home negative pressure ventilation in patients with severe chronic obstructive pulmonary disease. Active negative pressure ventilation was compared with a sham version of the treatment after a pre-trial assessment had indicated the feasibility of the latter. Over 1200 patients in the metropolitan Montreal area were screened. Of these, 348 patients were recruited to enter a 4-week stabilization period, and 184 were subsequently randomized to receive either active or sham negative pressure ventilation. A 5-day in-hospital period was used to train patients in ventilator use and obtain baseline measures of exercise capacity, lung function, respiratory symptoms, and quality of life. Home ventilation treatment took place during a following 12-week period. Respirator use was recorded both from patient logs and from concealed meters installed in the units. Patients received four home visits by physiotherapists during the 12-week period and returned for follow-up to the hospital 4 and 12 weeks post-discharge for reassessment.

Factors relevant to preventing embolic stroke in patients with non-rheumatic atrial fibrillation.

Whether or not to treat patients with non-rheumatic atrial fibrillation with anticoagulants to prevent embolic stroke is a dilemma for physicians. If randomized trials, currently underway, demonstrate a beneficial effect, the dilemma will not be solved because not all of the relevant factors can be addressed by trials. We used current knowledge about non-rheumatic atrial fibrillation and a method of obtaining patient-derived weights for avoiding stroke from eight medically trained subjects, to determine the overall benefit of anticoagulants and to see what factors were relevant and what effect each might have in deciding whether to use anticoagulant therapy. Using standard assumptions, anticoagulants gave an expected benefit for all subjects. The expected benefit (expressed in terms of lives per 1000 saved due to anticoagulants) varied between 5.4 and 46.7. This benefit remained for all subjects when we did a sensitivity analysis for different rates of stroke prevented by anticoagulants and different rates of intracranial hemorrhage caused by anticoagulants. When we used different baseline rates of stroke and different impacts of major hemorrhagic complications the benefit disappeared for 3 and 4 subjects respectively. We found the factors that were most crucial to the decision will not be included in randomized trials; the weight that an individual would place on avoiding embolic stroke vs the risk of intracranial bleeding from anticoagulant therapy; and the rate of embolic stroke that could be expected for the subject at risk. Factors which will be measured in randomized trials, will change results less substantially: the increased risk of major hemorrhages; the proportion of strokes that could be prevented by treatment; the increase in risk of intracranial hemorrhage. This method of analysis suggests that for most patients anticoagulants are beneficial and that the most important factor in determining this result is the value that subjects put on different outcomes.

ESRD treatment modality selection: which factors are important in the decision?

UNLABELLED: The purpose of this study was to determine which factors are most important in choosing between ESRD treatments and to assess if patients, R.N.'s and M.D.'s agree or differ as to the level of importance of different factors. METHODS: 22 patients, 11 R.N.'s and 10 M.D.'s were interviewed to determine which factors should be considered. Forty-three factors were identified relevant to CAPD and hemodialysis. Then 14 patients, 8 R.N.'s and M.D.'s were asked to rate each of these factors on a scale of 1-10 (10 being most important) and the average score for each was computed. The factors were then ranked in order of importance (1 being most important). The results revealed that peritonitis ranked as overall the most important factor in determining treatment modality choice. In general, life style considerations ranked higher than medical consequences of a specific therapy. There was concordance amongst the three groups in some areas but there were also differences between patients, R.N.'s and M.D.'s. This raises important issues with regards to the adequacy of patient counselling.

Assessing methods for causality assessment of suspected adverse drug reactions.

Reproducibility and validity as currently defined are inappropriate criteria for the evaluation of methods for causality assessment. Reproducibility leads to suppression rather than resolution of real disagreements and the method used to establish validity relies on the tarnished gold standard of expert opinion. We describe six alternative criteria that attempt to address a potential user's main concerns--the need to know whether to believe the results in general and in a particular case. These criteria focus on the internal structure of a method rather than its output. When we assessed the published methods by these criteria most of the methods failed most of the criteria. We believe that the problem and its solution lie at a fundamental level--real understanding of the true nature of causality assessment, which we suggest is an inherently subjective evaluation based on the multiple uncertainties that an assessor has about a case and not an objective attribute of the drug-event connection that can be determined from unambiguous evidence elicited in response to "operational questions".

A study on intrauterine fetal resuscitation with terbutaline.

A randomized study on the effect of terbutaline on fetal distress was carried out in 20 patients who showed evidence of ominous fetal heart rate patterns and fetal scalp blood pH values of less than 7.25. Of those, 11 received terbutaline (study group) and nine did not (control group). There was a significant improvement in the acid-base status of the fetus in the study group compared with those in the control group (p less than 0.01). No significant maternal or fetal morbidity occurred in the study group. Apgar scores at 1 minute were 7 or greater in 10 of the 11 study subjects whereas only four of the nine control subjects had a score of 7 or greater. These results suggest that terbutaline may become a useful agent in the treatment of intrauterine fetal distress.

Interobserver agreement by auscultation in the presence of a third heart sound in patients with congestive heart failure.

Although the third heart sound (S3) is well recognized as an important sign in the evaluation of patients with congestive heart failure, the interobserver variability with its observation needs to be known before general applicability can be determined. Therefore, we determined the agreement among four trained observers on the presence of S3 in 81 hospitalized patients. Agreement between pairs of observers varied between 48 and 73 percent. The kappa statistic, which adjusts for agreement by chance alone, showed that agreement between various observer pairs was moderate (kappa = 0.40-0.50) at best and slight (kappa = 0.10-0.30) at worst. The rate of agreement did not appear to be affected by the time interval between measurements, by the sex of the patient or by a training effect over the time of the study. In conclusion, although S3 may be important as a clinical sign, clinicians cannot agree reliably about whether or not it is present.

The notion of "acceptable risk": the role of utility in drug management.

This paper presents a definition of "acceptable risk" that is based on the concept of utility. The adverse effects of a specific use of a drug pose an acceptable risk if no alternative treatment has a higher cumulated expected utility in the relevant patient population than that associated with the use of the drug. The implications of this definition for postmarketing management of drugs are explored. In particular, postmarketing surveillance should be expanded to include the quantification of patients' values, a drug's beneficial effects, and its adverse effects. Management actions should be targeted at specific drug uses with unacceptable risks rather than at drugs themselves. This may require the use of education and service action options, as well as regulatory actions aimed at prescribers and dispensers.

Analgesic use, blood dyscrasias, and case-control pharmacoepidemiology. A critique of the International Agranulocytosis and Aplastic Anemia Study.

The International Agranulocytosis and Aplastic Anemia Study (IAAAS) of analgesic-induced risks of blood dyscrasias represents the current "state of the art" in case-control pharmacoepidemiology. We present a conceptual framework for examining the goal, methods, and analysis of an epidemiologic study of drug risks and review the IAAAS within this framework. In our view, the new risk estimates reported by the IAAAS are not inherently more accurate than existing ones, nor have they been measured in clinically and sociodemographically relevant groups of patients over the anticipated course of therapy. Thus, the reported risks cannot be used to guide clinical or regulatory decisions concerning available treatment options for such patients. Furthermore, we believe that the IAAAS methods for selection of cases and controls, ascertainment of exposure, and data analysis may well have led to invalid estimates even for those risks that are reported. We hope that closer attention to the conceptual framework we suggest and the methodologic issues we raise will enable future case-control pharmacoepidemiologic studies to provide more useful and accurate answers to questions concerning the adverse effects of drugs.

A prospective study on the impact of the renal biopsy in clinical management.

A three year prospective study involving 80 patients was conducted to assess the impact of renal biopsy on clinical management. Pre-biopsy predicted histologic diagnosis was changed in 35 (44%) of the patients as a result of the biopsy. Prognosis changed in 45 (57%) of the patients. Therapy changed in 25 (31%) of the patients. These results suggest that, overall, renal biopsy had a marked effect on management. However, we identified subgroups of patients who were unlikely to have their management changed as a result of the biopsy: of 16 patients with a pre-biopsy diagnosis of IgA nephropathy, 1 (6%) had treatment changed because of the biopsy; and of the 50 patients without heavy proteinuria (greater than 3 g/24 h), 10 (20%) had treatment changed because of the biopsy. Although our overall results suggest an important role for renal biopsy in clinical management, renal biopsy has the least apparent impact in patients with a pre-biopsy diagnosis of IgA nephropathy or without heavy proteinuria.

Kidney transplantation in Canada, 1981-84.

The Canadian Renal Failure Register was established in 1980. Data have been collected annually for all Canadian patients in whom irreversible kidney failure developed and who required dialysis or transplantation. The authors present actuarial patient and graft survival rates for 1981-84. In 1984, patients with a functioning renal graft accounted for 43.9% of the patients with end-stage renal disease. The number of transplants performed increased from 482 in 1981 to 662 in 1984; however, 1,022 patients undergoing dialysis (25.2%) were on an active waiting list for a transplant at the end of 1984. Greater effort is needed to increase the transplantation rate.