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.

Physician perspectives on the ethical aspects of disability determination.

OBJECTIVE: To evaluate physician's attitudes and responses to the ethical conflicts involved in certifying patients for welfare disability. DESIGN: A mailed questionnaire survey that used case scenarios and general questions. SETTING: Massachusetts. PARTICIPANTS: A random sample of 347 internists and family practitioners and a convenience sample of 100 neighborhood health center physicians from three large cities (NHC sample). The response was 53% and 76%, respectively. MEASUREMENTS AND MAIN RESULTS: Physician responses to case scenarios representing difficult decisions about patient requests for welfare disability determination and general questions about the welfare disability system. Physicians reported a willingness to exaggerate clinical data to help a patient they thought deserving of welfare disability benefits (39% random sample; 56% NHC sample). Physicians did not report confidence in their ability to determine who was disabled as measured by a visual analog scale (4.4 cm random sample, 4.6 cm NHC sample; 0 = very confident, 10 = very uncertain). They did feel burdened by their participation in welfare disability determinations when compared with other administrative chores as measured on a visual analog scale (2.8 cm random sample, 2.5 cm NHC sample; 0 = more burdensome, 10 = less burdensome). Eighty-two percent of the random sample physicians and 86% of the NHC sample physicians thought that filling out a disability form could adversely affect the physician-patient relationship, and 62% of physicians in each sample thought that it represented a conflict of interest. Eighty percent of physicians in both samples thought that it would be better if an independent group of physicians were designated to determine disability. CONCLUSIONS: Physicians perceive an ethical bind as they try to satisfy the conflicting demands of patients and the welfare disability system. They will frequently decide in favor of their patient's interests. This has implications for welfare policy planners.

The empathic physician.

Empathy is a process for understanding an individual's subjective experiences by vicariously sharing that experience while maintaining an observant stance. It is a useful tool in the medical encounter as it provides the physician with a fuller, more personalized view of the patient, and it provides the patient with a sense of connectedness to the physician that may allow him/her to more freely express his/her emotional distress. The roots of empathy are explained as a process that evolves from a developmental substrate with the addition of relevant experience, memory, and fantasy. While understanding the patient alone is a worthwhile goal, the physician's empathic insight can have therapeutic impact by its reflection back on the patient, through the use of language, to express support or sympathy, to justify behavior, or to foster deeper emotional expression.

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.

Basilar segmental bronchi: thin-section CT evaluation.

Thin (1.5- and 5.0-mm) section contiguous computed tomographic (CT) scans obtained through the basilar segmental bronchi in 31 patients were reviewed in order to delineate normal anatomy and common variations of lower lobe airways. In each case, the frequency with which individual segmental and subsegmental bronchi were seen was established, as were variations in branching patterns. All basilar segmental bronchi were identified except in one case in which images of the left lung were obscured due to respiratory and cardiac motion. In the right lung, a division into subsegmental bronchi was identified in 84 of 150 (56%) visualized segmental bronchi. Six separate patterns of basilar segmental subdivision were found. In the left lung, subsegmental bronchi were identified arising from 51 of 145 (35%) visualized segmental bronchi. Five separate patterns of bronchial subdivision were found in the left lung. It is concluded that thin-section CT allows precise identification of all basilar segmental bronchi and, consequently, can play a significant role in the cross-sectional evaluation of lower lobe bronchial and parenchymal abnormalities.

Dynamic stereoacuity: a test for hitting a baseball?

Vision is a critical ingredient in professional sports such as baseball. It would, therefore, be logical to assume that vision testing should be able to discriminate between good and bad performance. Past attempts to establish this vision/performance relationship have not been successful. We believe the fault is anchored in the fact that all routine vision testing is static and unable to measure motion parameters. Using an instrument of our design to test dynamic stereoacuity, we have been able to detect subtle differences among individuals. The data show a segregation between major league hitters and pitchers. Such information could be used as one clue to predict hitting performance.

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.

Fluid within preexisting pulmonary air-spaces: a potential pitfall in the CT differentiation of pleural from parenchymal disease.

There have been many reports of the ability of CT to distinguish between parenchymal and pleural disease. The purpose of this report is to describe the appearance of seven cases of intraparenchymal fluid-filled air-spaces (bullae or lung cysts) in which the CT findings may resemble those of pleural disease and, thus, cast doubt on the specificity of the established criteria.