"My most meaningful patient". Reflective learning on a general medicine service.

OBJECTIVE: To determine the usefulness of critical-incident reports in facilitating reflective learning and the types of experiences that learners found meaningful on a general medicine service. DESIGN: Team members wrote about their most meaningful patient of the month and what was learned from the patient. They shared their narratives during teaching rounds at the end of each month. The written reports were collected and subjected to qualitative thematic analysis. SETTING: General medicine teaching service of an academic medical center. PATIENTS/PARTICIPANTS: Medical students, residents, and attending physicians. MEASUREMENTS AND MAIN RESULTS: Ninety-eight reports were collected over 10 months and subjected to thematic analysis. Reports were coded for six major themes, with a mean of 2.09 themes per narrative. The number of reports containing each theme was 47 for biomedical, 46 for communication with patients and families, 38 for psychosocial, 32 for the physician's role, 30 for personal feelings, and 14 for ethics. Communication issues constituted the theme most frequently reported by third-year students; biomedical and psychosocial themes by interns; biomedical by supervising residents; and the physician's role by attending physicians. Reports from men and women contained a similar mean number (men 2.101; women 2.128) and distribution of themes. CONCLUSIONS: The critical-incident technique promoted reflection on the meaning of clinical experiences. Qualitative thematic analysis revealed the diversity of meaningful experiences on a general medicine service and the high frequency of nonbiomedical themes. This study suggests that reflective exercises can provide a window into the experience of students and residents.

Impact of pharmaceutical company representatives on internal medicine residency programs. A survey of residency program directors.

To survey internal medicine residency program directors regarding interactions between their residents and pharmaceutical company (PC) representatives (PCRs) a questionnaire was sent to the directors of all Accreditation Council for Graduate Medical Education-approved internal medicine residency programs. The survey included 444 program directors, of whom 272 (61.16%) responded. The majority of program directors, 228 (83.8%), allowed PCRs to meet with residents during working hours and 241 (88.6%) permitted PC sponsorship of conferences. About half of the program directors were "moderately" or "very" concerned about the potential adverse effects of PC marketing on resident attitudes and prescribing practices. Seventy percent "agreed" or "strongly agreed" that the benefits of PC sponsorship outweigh the adverse effects and 41.5% believed that refusal to allow PCRs to meet with residents would jeopardize PC funding of other departmental activities. Most program directors reported that alternate funds for conferences were available if PC support was withdrawn. "Unethical" marketing activities were observed by 14.3% of program directors and 37.5% reported that residents had participated in PC-sponsored trips during the 3 years prior to the survey. At the time of this survey, only 35.3% of programs had developed formal policies regulating PCR activities and 25.7% provided residents with formal instruction on marketing issues. Knowledge of the current extent of PCR interactions with residents may be helpful to program directors in developing policies regulating PC-marketing activities.

Knowledge, attitudes, and behavior of elderly persons regarding living wills.

The knowledge, attitudes, and behavior of elderly persons regarding living wills were explored in a rural county in eastern North Carolina. A questionnaire was administered to 75 ambulatory elderly persons by personal interview at community dining sites. Fifty-two percent (39) of these subjects said they were familiar with living wills and 64% (48 persons) correctly summarized what the North Carolina living will says. When asked about preferences for medical care in the setting of a terminal illness, 86% (65 persons) stated a desire to receive basic medical care or comfort care only. Although their preferences were consistent with the provisions of a living will, none had signed the living will document provided by the state of North Carolina, and only two (3%) had discussed a living will with their physician. Seventy (93%) wanted their family or spouse to make decisions about terminal care if they themselves were unable to participate, and discussions between these persons and their chosen proxies actually occurred 45% (34/75) of the time. Eighty-one percent (61 persons) stated a desire to discuss end-of-life care with their physicians, but a minority (eight [11%]) had actually talked with their physicians, and these discussions were usually initiated by the patient (five of eight). We conclude that living will legislation is congruent with the desire of many elderly persons to limit medical care in terminal illness. However, this elderly population did not make use of living wills as a means of indicating their wishes. Recommendations are made to improve physician-patient and patient-proxy communication regarding preferences for medical care at the end of life and living wills. Alternatives to the living will should also be explored.

Caring for the patient with multiple somatic complaints.

Patients with multiple somatic complaints but little disease are commonly seen in most medical practices. Their behavior can be understood by considering the contribution of psychologic, perceptual, and social factors in the etiology and maintenance of the illness complaint. Because these patients cling to their symptoms, care rather than cure is the cornerstone of management. Recommendations for patient care are based on a multifactorial model of symptom etiology. The doctor-patient relationship is central to therapy.

Response of plasma beta-endorphins to transcutaneous electrical nerve stimulation in healthy subjects.

A study of 31 healthy volunteers was done to test the hypothesis that analgesia produced by low frequency/high intensity (LoF/Hil) transcutaneous electrical nerve stimulation (TENS) is mediated by release of beta-endorphin (beta-E). After randomization, Group 1 (n = 10) received no stimulation (placebo); Group 2 (n = 9) received 30 minutes of high frequency/low intensity (HiF/Lol) TENS; and Group 3 (n = 12) received 30 minutes of low frequency/high density (LoF/Hil) TENS. Blood pressure, pulse, plasma beta-E levels, and evoked potential response were measured before and after treatment. Mean plasma beta-E increased with treatment in Groups 2 and 3 and fell in Group 1, but the difference between the groups was not statistically significant. Sixty-seven percent of Groups 2 and 3 showed an increase in plasma beta-E levels compared with 30 percent in Group 1 (two-sample test of proportions, p less than .05). Evoked potential response, a measure of pain threshold, varied directly with plasma beta-E level independent of the type of treatment applied. This study did not demonstrate a difference between the effects of HiF/Lol versus Lof/Hil TENS on plasma beta-E in healthy subjects.

The resident leaves the patient: another look at the doctor-patient relationship.

The clinics of primary care training programs face the annual problem of residents leaving their patients. The responses of the resident physician and the patient can be understood in terms of the grieving process. Feelings of anger, guilt, anxiety, and fear may complicate this phase of the resident-patient relationship and threaten continuity of care. Maladaptive behaviors may result if negative responses to separation go unacknowledged. An appreciation of the range of both patient and resident responses will aid in establishing rational guidelines for ending relations and transferring patient care.