Health-related quality of life and posttraumatic stress disorder in survivors of the acute respiratory distress syndrome.

OBJECTIVES: Despite considerable progress in intensive care management of the acute respiratory distress syndrome (ARDS), little is known about health-related quality of life in long-term survivors. In addition, intensive care treatment can be extremely stressful, and many survivors of ARDS report adverse experiences such as respiratory distress, anxiety, or pain during intensive care unit (ICU) treatment. This study was performed to assess health-related quality of life in survivors of ARDS and to test the hypothesis that adverse experiences during ICU treatment result in posttraumatic stress disorder (PTSD) and negative effects on health-related quality of life. DESIGN: Retrospective, cohort, case-controlled analyses. SETTING: A 12-bed multidisciplinary ICU of a tertiary care university hospital, capable of providing extracorporeal life support for adults with severe ARDS. PATIENTS: We studied 80 patients who were admitted to our hospital from 1985 to 1995 and who survived an episode of ARDS. ARDS was defined according to the criteria of the American-European Consensus Conference on ARDS. INTERVENTIONS: Health-related quality of life was measured using the Health Status Questionnaire of the self-administered Medical Outcomes Study Short Form Survey that consists of 36 questions (SF-36) and the German version of the Post Traumatic Stress Syndrome 10-Questions Inventory (PTSS-10), a self-report scale for the diagnosis of posttraumatic stress disorder based on the Diagnostic and Statistical Manual (Third Edition) criteria (American Psychiatric Association). The number of adverse experiences (anxiety, respiratory distress, pain, and nightmares) during intensive care was evaluated by means of a structured questionnaire. For each patient with ARDS, three age- and gender-comparable controls were randomly selected from databases providing normal values for the SF-36 and PTSS-10 scores in populations at risk for posttraumatic stress disorder. MEASUREMENTS AND MAIN RESULTS: Survivors of ARDS showed statistically significant impairments in all eight health dimensions of the SF-36 when compared with normal controls (median reduction 21.3%, p < .006) with maximal impairments in physical function (median reduction 28.9%, p = .000) and a 38% higher frequency of chronic pain (p = .0001). Three of 34 patients reporting none, or one, adverse experience had evidence of posttraumatic stress disorder vs. 19 of 46 patients remembering multiple traumatic episodes (p = .007). Patients reporting multiple adverse experiences described the lowest health-related quality of life, with maximal impairments in psychosocial functioning (p < .005) and only small limitations in physical function. CONCLUSIONS: Long-term survivors of ARDS describe a good overall health-related quality of life. Major impairments in mental health domains of health-related quality of life are associated with the development of posttraumatic stress disorder and are a possible result of traumatic experiences during ICU therapy.

Psychosomatic education in West Germany.

Psychosomatic medicine (PsM) is taught to nearly all of the 12,000 West German medical students. It has become part of the curriculum by legal act (1972) and now forms part of the national syllabus. There are independent university departments in PsM at approximately three-quarters of the 27 medical schools in West Germany. In approximately two-thirds of the medical schools PsM is taught by members of departments lacking close working links with departments of non-psychiatric health services. The topic of liaison psychiatry is virtually excluded from the national syllabus. In teaching sessions, patients with psychogenic disorders predominate, which may bias the attitudes of students. The overall reception of PsM by students is fair to good although their expectations must be dealt with carefully. Many complain that the teaching in this subject is too short. Some of them (20-30%) can be motivated to join electives in PsM. These electives are related to patient care and involve team working and may be exemplified by the so called "Peer Groups on History Taking". Members of these groups practice guided self-help and this in part overcomes the dissatisfaction amongst students caused by overpopulation of the medical school. In conclusion it is suggested that in West Germany, students should be exposed more often to places of primary care, and their lecturers should act as experts in group techniques applied to problem situations in primary care. Psychosomatic lecturers should concentrate on issues of primary care and act as supervisors of group work. They should also support student electives in PsM in order to promote interest in this subject.

Can medical students acquire patient centered attitudes at medical schools?

Progress in psychosomatic medicine will largely depend on the kind of attitudinal learning that takes place at medical schools. What can be achieved by a patient-centered training programme emphasizing attitudinal learning? In a research programme 350 students were introduced to principles of patient-centered medicine in so-called peer groups on history taking ('Anamnesegruppen'). By the end of group work, students exhibited more realistic and less defensive expectations towards the patients and felt more confident about their peers' support. The interviewing skills had improved. The training scheme appeals to approximately 20% of the students. It has been adopted by various other places in the Federal Republic of Germany and Switzerland. Basic institutional aids became apparent: access to patients, supervision, regional meetings. It is assumed that students learn how to link role performance with personal self-awareness, how to trust and be accepted, how to face the faculty. Four overlapping stages basic to the learning process (exposing, reflecting, acting, progressing) are discussed. It is concluded that in medical schools patient-oriented attitudinal learning is possible. Peer learning seems to be decisive. Interdisciplinary research into peer learning is recommended.

Does history-taking affect learning of attitudes?

QUESTION: How can medical students adopt a patient-oriented approach? SETTING: During the past 7 years approximately 60 preclinical and clinical students joined dynamically oriented group sessions on medical history-taking. An open-ended question technique was used. EVALUATION: The student's expectations of the patient were monitored by the repertory grid technique using a self-developed dyad grid form which allowed the estimation of reciprocal expectations as seen by the student. A main component analysis of the ratings obtained was performed. RESULTS: The development in one group was taken as representative of the general development in the different groups. Two main components (MC I, II) were found to account for approximately 40 and 25% of the total variance (distance/empathy and dominance/dependence). The student's main concern is centered on the problem of dependence, MC II. He expects the patient to cling to him. Similarly he feels dependent on the psychosomatic lecturer. He feels as though he is the lecturer's patient. During group work the patient is seen to be less clinging. The student learns that he is not his lecturer's patient but his junior partner. He changes his professional ego-ideal as a future doctor. This is modelled according to his own relationship with the lecturer. It is not modelled according to the usual doctor-patient relationship as perceived by the student. The main characteristic of the change is a lessening of dependency needs as felt in the relationship to the patient. INTERPRETATION: The findings are interpreted as an attitudinal change in favour of a more patient-oriented attitude. The change was affected through confrontation with the patient's needs. Conclusions were drawn: The student has to be trained how to cope with dependency needs. Special learning settings have to be provided which are staffed with patient-oriented physicians.

Training in anger: how not to communicate with one's medical seniors.

Meyer and Mendelson (2) have identified four critical situations which influence the interaction of consultant and consultee, namely, (1) inappropriate setting; (2) threat through disease and death; (3) character disorders; (4) family and social pathology. Feeling states of hopelessness, pessimism and despair are induced in both consultant and consultee and may lead to a breakdown of their working alliance. It is postulated that the breakdown is programmed by the physicians' basic attitudes towards coping with dependency needs are ignored by the faculty of not being patient-oriented (5). Covert or open hostility towards the faculty is manifested (10). Basic professional needs are not discussed with one's medical seniors who are seen in anger. If liaison medicine is to become effective, its proponents have to direct their attention towards attitudinal learning during undergraduate study. This will require supervised exposure to patients needs, assuming increasing responsibility, individual and faculty feedback.

The doctor-patient relationship in the practice of medicine.

The patient-doctor relationship is based on the principles of interaction, collecting data and integration of both interaction and data into an overall diagnosis/therapy. Patients with functional abdominal disorders are seen as representatives of today's general patients and a study of their management in present medical practice is reported, as revealed through literature. The literature reveals an almost complete neglect of intractional and intergrational principles. This holds true even for psychosomatically oriented literature, which offers some crude clinical guidelines at best. Thus the primary physician gets little support from psychosomatic medicine in understanding the full meaning of the doctor-patient relationship. The clinical implications of the relationship are demonstrated through a short case history and implications for future training are described which are based on the primary physician's actual working experiences.

Evaluation of combined pharmacological and psychotherapeutic treatment in patients with functional abdominal disorders.

78 patients suffering from various functional abdominal complaints have been trated in a 2 x 2 double-blind design: (a) psychotherapy with Ro 5-3350 (TH/Ro); (b) psychotherapy with placebo (TH/P); (c) Ro 5-3350 without psychotherapy (NIH/Ro); (d) placebo without psychotherapy (NTH/P). Results show that a considerable amount of improvement cannot be ascribed to the two critical factors or the interaction of both, but are due to unspecific influences in the course of treatment. Some of the results concerning the combination of TH and the psychotropic drug pose interesting questions for further research and bare implications for double-blind trials of psychotropic drugs. The results suggest that possibly properties of any psychotropic drug have to be related to a doctor-patient relationship within which the personal problems of the patient are dealt with. In order to evaluate such properties, special methodological precautions have to be taken. These will be briefly discussed.