The effect of medical education on primary care orientation: results of two national surveys of students' and residents' perspectives.

PURPOSE: To examine changes among a nationally representative sample of students and residents in their orientations toward primary care as reflected in their attitudes toward the psychosocial and technical aspects of medicine and their perceptions of the academic environment for primary care. METHOD: Confidential telephone interviews of stratified national probability samples of first- and fourth-year medical students and residents were conducted in 1994 and 1997. The 1997 survey included 219 students and 241 residents who had also been interviewed in 1994. Participants were asked about their attitudes toward addressing psychosocial issues in medicine and their perceptions of faculty and peer attitudes toward primary care. Responses were compared over time and across groups. RESULTS: Between the first and fourth years of medical school, there was a decline over time in students' reported orientations to socioemotional aspects of patient care (61.6% versus 42.7%, p =.001) and their perceptions that working with psychosocial issues of patients made primary care more attractive (56.3% versus 43.5%, p =.01). This pattern continued for 1997 residents (PGY-3), who were even less likely to say that addressing psychosocial issues made primary care more attractive (26.9%). For fourth-year students in 1994 who became PGY-3 residents in 1997, there was an increased perception that non-primary-care house officers and specialty faculty had positive attitudes toward primary care (20.8% versus 33.0%, p =.005; 28.3% versus 45.7%, p <.0001; respectively). CONCLUSIONS: Between 1994 and 1997 students and residents perceived a positive shift in the attitudes of peers and faculty toward primary care. During the course of their education and training, however, the students experienced an erosion of their orientations to primary care as they progressed through medical school into residency.

Enthusiasm for primary care: comparing family medicine and general internal medicine.

OBJECTIVE: To compare attitudes and perceptions of primary care among faculty, students, and residents oriented toward family medicine (FM) and general internal medicine (GIM). DESIGN: Descriptive study using confidential telephone interviews. PARTICIPANTS: National stratified probability sample of FM and GIM faculty (n = 68), residents (n = 196), and students (n = 81). MEASUREMENTS AND MAIN RESULTS: We created indicators for attitudes toward primary care among the faculty that included perceptions of medical practice, experiences within the academic environment, and support for primary-care-oriented change. For the students and residents, we explored their perceptions of faculty and resident attitudes toward primary care, their perception of encouragement to enter primary care, and their satisfaction with training. Family medicine faculty showed more enthusiasm for primary care as manifested by their greater likelihood to endorse a primary care physician to manage a serious illness (FM 81.3% vs GIM 41.1%; p < .01), their strong encouragement of students to enter primary care (FM 86.2% vs GIM 36.3%; p < .01), and their greater support for primary-care-oriented changes in medical education (FM 56.8% vs GIM 14.7%; p < .01). Family medicine students and residents were more likely to perceive the primary care faculty as very satisfied with their work (FM 69.2% vs GIM 51.5%; p < .05), to feel strongly encouraged by peers toward primary care (FM 59.5% vs GIM 16.1%; p < .0001), and to have a primary care role model (FM 84.3% vs GIM 61.3%; p < .05). CONCLUSIONS: Family medicine faculty, students, and residents showed a consistent pattern of greater enthusiasm for primary care than their GIM counterparts. This may be a reflection of the different cultures of the two disciplines.

Transference phenomena in medical practice: being whom the patient needs.

Transference is a process in which individuals displace patterns of behavior that originate through interaction with significant figures in childhood onto other persons in their current lives. It is a powerful determinant of patient behavior in medical encounters. Transference can affect the kind of physician-patient relationship a patient seeks and his or her response to interventions prescribed by physicians. The relationship is also strongly affected by the physician's own transference or countertransference. Rather than approach every patient in a uniform way, tailoring the approach to fit the relationship needs of the individual patient is advocated. Such tailoring would affect whether the physician is collaborative or prescriptive, how much personal information he or she shares, and how close or distant he or she is. Transference issues can also affect level of somatization and patient adherence to medical regimens. We discuss other problems with transference, such as the seductive patient and gift giving. By paying attention to the transference needs of patients, physicians can enhance the therapeutic alliance in which patients optimally participate in fulfilling their medical needs.

Doctors have feelings too.

The medical encounter, like all human interaction, is unavoidably emotion laden. Rather than viewing them as something to be overcome, the emotional responses of the physician can be analyzed for information about the patient or about the physician. The emotional states of patients arouse complementary reactions in the clinician that are diagnostic clues to important clinical syndromes such as depression or character disorders. Conversely, the physician can have idiosyncratic responses to patients that can lead to inappropriate diagnostic and therapeutic choices or to avoidance of particular problems or patients. Self-awareness is the key to utilizing these reactions to improve the patient-physician relationship.

Circulating anticoagulant associated with chronic active hepatitis.

Chronic active hepatitis is frequently associated with a variety of serologic abnormalities. A patient with chronic active hepatitis and a circulating anticoagulant to factors XI and XII is described. Circulating anticoagulants should be suspected in patients with chronic active hepatitis and a prolonged partial thromboplastin time. This risk of liver biopsy in these patients is unknown, but this possible hazard should be considered in all patients with chronic active hepatitis.

The transitional vertebra of the lumbosacral spine: its radiological classification, incidence, prevalence, and clinical significance.

This report presents interim results from a series of studies of the lumbosacral region of the spine. A new classification of the lumbosacral transitional vertebra (LSTV) is proposed. An LSTV was found with similar frequency in patients and in population samples. The radiological findings were related to the presence of symptoms and to evidence of urological problems. Whilst Brocher (1973), Rubin (1971), and others have considered an LSTV to be of importance because it should lead to unfavourable weight bearing in the lower spine, the present extensive material shows that there is no relation between an LSTV and low backache. There may be a genetic factor involved in the various types of LSTV.