When doctors marry doctors: a survey exploring the professional and family lives of young physicians.

BACKGROUND: Soon, half of all physicians may be married to other physicians (that is, in dual-doctor families). Little is known about how marriage to another physician affects physicians themselves. OBJECTIVE: To learn how physicians in dual-doctor families differ from other physicians in their professional and family lives and in their perceptions of career and family. DESIGN: Cross-sectional survey. SETTING: Two medical schools in Ohio. PARTICIPANTS: A random sample of physicians from the classes of 1980 to 1990. MEASUREMENTS: Responses to a questionnaire on hours worked, income, number of children, child-rearing arrangements, and perceptions about work and family. RESULTS: Of 2000 eligible physicians, 1208 responded (752 men and 456 women). Twenty-two percent of male physicians and 44% of female physicians were married to physicians (P < 0.001). Men and women in dual-doctor families differed (P < 0.001) from other married physicians in key aspects of their professional and family lives: They earned less money, less often felt that their career took precedence over their spouse's career, and more often played a major role in child-rearing. These differences were greater for female physicians than for male physicians. Men and women in dual-doctor families were similar to other physicians in the frequency with which they achieved career goals and goals for their children and with which they felt conflict between professional and family roles. Marriage to another physician had distinct benefits (P < 0.001) for both men and women, including more frequent enjoyment from shared work interests and higher family incomes. CONCLUSIONS: Men and women in dual-doctor families differed from other physicians in many aspects of their professional and family lives, but they achieved their career and family goals as frequently. These differences reflect personal choices that will increasingly affect the profession as more physicians marry physicians.

Evaluation of a treatment limitation policy with a specific treatment-limiting order page.

BACKGROUND: Concerns about misinterpretation, misunderstanding, poor communication, and lack of documentation prompted a revision of our hospital's treatment limitation policy. The revised policy was designed to explicate do-not-resuscitate (DNR) orders, structure the use of DNR and other treatment-limiting orders in a logical and standard way, and improve communication. Use of a Specific Treatment-Limiting Order Page (STOP) was required. METHODS: To evaluate the policy's effects, we conducted (1) a prospective cohort study (involving 2733 patients) of treatment limitation practices before and after the new policy and (2) cross-sectional surveys of 58 nurses and 62 physicians. Outcome measures included documented treatment-limiting orders, documented discussions of these decisions, and deaths. Staff opinions about effects on communication and patient care were elicited. RESULTS: Rates of death (5.4% before and 5.6% after the policy; P = .80) and rates of DNR orders (9.3% vs 9.2%, P = .9) did not change. The use of the STOP enhanced the clarity of DNR orders and, among DNR patients, greatly increased the frequency of orders limiting 12 other specific treatments for conditions short of arrest. For example, before the policy, orders prohibited mechanical ventilation in 2% of DNR patients, compared with 66% after the policy (P < .001). Staff reported that the policy improved communication among health professionals, patients, and families. CONCLUSIONS: The treatment limitation policy with the STOP improved documentation and communication of treatment-limiting decisions. On the basis of our results, we offer a STOP for use and evaluation by others.

'Brain death' and organ retrieval. A cross-sectional survey of knowledge and concepts among health professionals.

A sample of 195 physicians and nurses likely to be involved in organ procurement for transplantation was interviewed about knowledge, personal concepts, and attitudes concerning "brain death" and organ donation. Only 68 respondents (35%) correctly identified the legal and medical criteria for determining death. Personal concepts of death varied widely. Most respondents (58%) did not use a coherent concept of death consistently; others (19%) had a concept of death that was logically consistent with changing the whole-brain standard to classify anencephalics and patients in a persistent vegetative state as dead. The findings demonstrate confusion about correct criteria for determining death and differences in concepts of death that might prove troublesome to the transplantation enterprise. We conclude that health professionals should do more to resolve the clinical and conceptual issues in the definition and determination of death before policies concerning organ retrieval are changed.

KIE: The authors surveyed 195 physicians and nurses likely to be involved in organ procurement for transplantation to determine knowledge, personal concepts, and attitudes concerning brain death and organ donation. Thirty-five percent of those surveyed correctly identified the legal and clinical criteria for determining death. There was a wide variation in personal concepts of death, with most respondents not using a coherent concept consistently. Others held a concept of death that was consistent with expanding the definition of brain death. Twenty-three percent of the respondents opposed required request laws. The authors conclude that their survey demonstrates confusion about determining death and differences in concepts of death that have implications for procurement of organs for transplantation. They recommend that health professionals do more to resolve the issues in the definition and determination of death.

'Do not resuscitate' orders. Incidence and implications in a medical-intensive care unit.

"Do not resuscitate" (DNR) decisions were examined in a medical intensive care unit (MICU) of a 1,000-bed hospital. Seventy-one (14%) of 506 study patients were designated DNR; nine survived hospitalization. Severity of illness, age, and prior health were predictive of DNR orders; race and socioeconomic factors were not. The DNR patients consumed more resources, both before and after DNR orders. Interventions started before DNR designation were continued in at least 76% of patients. Documented justifications of DNR decisions included poor prognosis (59%), poor quality of life (24%), and patients' wishes (15%). There were no written justifications for the DNR decisions in 30 cases (42%). Although willingness to write DNR orders in an MICU and continued active treatment of DNR patients are both reassuring in a general sense, they raise questions about the consistency of treatment plans and goals for individual patients.

KIE: A study was conducted of "do not resuscitate" (DNR) decisions written for 71 patients in a medical intensive care unit of a large university hospital. Fifty-eight percent of the medical records contained justifications for the DNR decisions and analysis revealed that these decisions were not influenced by racial or economic considerations but by medical diagnostic and prognostic criteria. DNR patients continued to receive high levels of active treatment equal to or in excess of other intensive care unit patients. The authors express concern that this level of medical intervention may indicate overtreatment and waste of resources.

ICU visiting policies.

Head nurses from 78 ICUs in 37 northeast Ohio hospitals were interviewed about visiting policies. There was tremendous variation with regard to frequency and length of visits; 25% of these ICUs allowed only 2 visits/day, and 42% restricted visits to under 20 min. Most units rarely or never allowed children under 12 yr old to visit. Traditional rationales for restricted visiting are not supported by studies in the literature, nor are they consistent with current concepts of patients' rights. In an era where high technology and medicine by-the-numbers threaten to dehumanize patients, open visiting is an important part of the humanization process.

A national survey of hospital ethics committees.

A telephone survey of 602 randomly selected hospitals was conducted to identify existing ethics committees, i.e., those with the potential to become involved in the decision-making process in specific cases. Using the number of acute care beds as the criterion, hospitals were divided into 2 groups: (1) over 200 beds; n = 400; (2) 200 or fewer beds; n = 202. Chairpersons of identified committees completed detailed questionnaires. Seventeen committees were found--approximately 1% of all U.S. hospitals. A typical committee included physicians, clergymen, and other professionals. Almost all committees were advisory, not decision-making bodies, and considered very effective by their chairpersons. Ethics committees have not, however, solved current medical ethical problems; nor have they allayed the concerns of patients' rights advocates about patient representation and control. Further study is warranted.

A sexuality curriculum for gynecology residents.

PIP: A research project was conducted with the obstetrics and gynecology residents at University Hospitals of Cleveland in February 1976. The purpose was to provide residents with basic knowledge about female sexual problems, to assess the residents' skill and comfort in interviewing patients with sexual problems, to document the effects of supervision on interviewing skills, and to evolve a sexuality curriculum for residents in obstetrics and gynecology. 13 residents at various stages of training participated. The project's 5-1/2 hours were distributed over 2-1/2 weeks. 4 women were taught to respond as if they were patients with the following specific complaints: failure to develop sexual responsiveness, loss of responsiveness due to anger, loss of libido due to depression, and frustration becuase of an impotent husband. The sequence of activities was 1) required reading of a 2-page protocol for assessing a sexual complaint; 2) completion of a preinterview questionnaire which assessed comfort and skill measured on a 5-point scale, immediately followed by a 20-minute videotaped interview with the 1st patient; 3) reading of an article on female sexual dysfunction; 4) attendance at a 2-hour lecture on female sexual dysfunction and interviewing techniques; and 5) conduct of a 2nd, 3rd, and 4th interview over a 2-week period. Each interview was followed by a 45-minute session with the supervisor to view and discuss the videotape. As a group the residents' interviewing abilities failed to improve by the end of the program, as measured by total percentage of programmed content elicited; method of obtaining information, that is, direct or indirect questions; and style ratings. Recommendations are made concerning the educational needs of residents in obstetrics and gynecology.^ieng