Empathy in medical students as related to academic performance, clinical competence and gender.

CONTEXT: Empathy is a major component of a satisfactory doctor-patient relationship and the cultivation of empathy is a learning objective proposed by the Association of American Medical Colleges (AAMC) for all American medical schools. Therefore, it is important to address the measurement of empathy, its development and its correlates in medical schools. OBJECTIVES: We designed this study to test two hypotheses: firstly, that medical students with higher empathy scores would obtain higher ratings of clinical competence in core clinical clerkships; and secondly, that women would obtain higher empathy scores than men. MATERIALS AND SUBJECTS: A 20-item empathy scale developed by the authors (Jefferson Scale of Physician Empathy) was completed by 371 third-year medical students (198 men, 173 women). METHODS: Associations between empathy scores and ratings of clinical competence in six core clerkships, gender, and performance on objective examinations were studied by using t-test, analysis of variance, chi-square and correlation coefficients. RESULTS: Both research hypotheses were confirmed. Empathy scores were associated with ratings of clinical competence and gender, but not with performance in objective examinations such as the Medical College Admission Test (MCAT), and Steps 1 and 2 of the US Medical Licensing Examinations (USMLE). CONCLUSIONS: Empathy scores are associated with ratings of clinical competence and gender. The operational measure of empathy used in this study provides opportunities to further examine educational and clinical correlates of empathy, as well as stability and changes in empathy at different stages of undergraduate and graduate medical education.

Correlates of young physicians' support for unionization to maintain professional influence.

PURPOSE: A resolution in support of physicians' unionization was recently approved by the American Medical Association's House of Delegates. This study investigated the factors associated with young physicians' approval of unionization. METHOD: A survey was mailed to all 1987-1992 Jefferson Medical College graduates (n = 1,272); 835 (66%) responded. RESULTS: Of the respondents, 43% supported unionization, 31% did not support unionization, and 26% expressed no opinion. Surgeons, medical subspecialists, pediatricians, and hospital-based specialists were more likely to support unionization than were family physicians. Significant predictors of support for unionization were negative views of the changes in the health care system, negative perceptions of the quality of care provided by managed care, the belief that physicians' independence had been impaired by changes in the health care system, and the belief that physicians' personal satisfaction should take precedence over societal needs in determining the future of health care. Support for unionization correlated with physicians' perceptions that mental health patients should be referred to psychiatrists, physician-assisted suicide should be legalized, and the involvement of nurse practitioners in diagnosis and treatment could compromise the quality of care. CONCLUSIONS: Young physicians' support for unionization is a function of frustration with market-driven policies that compromise the quality of care and negatively affect physicians' autonomy and personal satisfaction.

Documenting and comparing medical students' clinical experiences.

CONTEXT: The decentralization of clinical teaching networks over the past decade calls for a systematic way to record the case-mix of patients, the severity of diseases, and the diagnostic procedures that medical students encounter in clinical clerkships. OBJECTIVE: To demonstrate a system that documents medical students' clinical experiences across clerkships. DESIGN AND SETTINGS: Evaluation of a method for recording student-patient clinical encounters using a pocket-sized computer-read patient encounter card at a US university hospital and its 16 teaching affiliates during academic years 1997-1998 through 1999-2000. PARTICIPANTS: A total of 647 third-year medical students who completed patient encounter cards in 3 clerkships: family medicine, pediatrics, and internal medicine. MAIN OUTCOME MEASURES: Number of patient encounters, principal and secondary diagnoses, severity of diseases, and diagnostic procedures as recorded on patient encounter cards; concordance of patient encounter card data with medical records. RESULTS: Students completed 86 011 patient encounter cards: 48 367 cards by 582 students in family medicine, 22 604 cards by 469 students in pediatrics, and 15 040 cards by 531 students in internal medicine. Significant differences were found in students' case-mix of patients, the level of disease severity, and the number of diagnostic procedures performed across the 3 clerkships. Stability of the findings within each clerkship across 3 academic years and the 77% concordance of students' reports of principal diagnosis with faculty's confirmation of diagnosis support the reliability and validity of the findings. CONCLUSIONS: An instrument that facilitates students' documentation of clinical experiences can provide data on important differences among students' clerkship experiences. Data from this instrument can be used to assess the nature of students' clinical education.

Attitudes toward physician-nurse collaboration: a cross-cultural study of male and female physicians and nurses in the United States and Mexico.

BACKGROUND: Inter-professional collaboration between physicians and nurses, within and between cultures, can help contain cost and insure better patient outcomes. Attitude toward such collaboration is a function of the roles prescribed in the culture that guide professional behavior. OBJECTIVES: The purpose of the study was to test three research hypotheses concerning attitudes toward physician-nurse collaboration across genders, disciplines, and cultures. METHOD: The Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration was administered to 639 physicians and nurses in the United States (n = 267) and Mexico (n = 372). Attitude scores were compared by gender (men, women), discipline (physicians, nurses), and culture (United States, Mexico) by using a three-way factorial analysis of variance design. RESULTS: Findings confirmed the first research hypothesis by demonstrating that both physicians and nurses in the United States would express more positive attitudes toward physician-nurse collaboration than their counterparts in Mexico. The second research hypothesis, positing that nurses as compared to physicians in both countries would express more positive attitudes toward physician-nurse collaboration, was also supported. The third research hypothesis that female physicians would express more positive attitudes toward physician-nurse collaboration than their male counterparts was not confirmed. CONCLUSIONS: Collaborative education for medical and nursing students, particularly in cultures with a hierarchical model of inter-professional relationship, is needed to promote positive attitudes toward complementary roles of physicians and nurses. Faculty preparation for collaboration is necessary in such cultures before implementing collaborative education.

Minimum instructional and program-specific administrative costs of educating residents in internal medicine.

BACKGROUND: The cost associated with education of residents is of interest from an educational as well as a political perspective. Most studies report a single institution's actual incurred costs, based on traditional cost accounting methods. We quantified the minimum instructional and program-specific administrative costs for residency training in internal medicine. METHODS: Using the Accreditation Council for Graduate Medical Education program requirements for internal medicine as minimum standards for teaching and administrative effort, we quantified the minimum instructional and administrative costs for sponsorship of an accredited residency program in internal medicine. We also analyzed the impact of resident complement and program curricular emphasis (outpatient, inpatient, or traditional) on the per-resident cost. The main outcome measure was the minimum annual per-resident cost of instruction and program-specific administration. RESULTS: Using the assumptions in this model, we estimated the annual cost per resident of implementing the program requirements to be $50,648, $35,477, $28,517, and $26,197 for inpatient intensive residency programs with resident complements of 21, 42, 84, and 126, respectively. For outpatient intensive residency programs of identical resident complements, we estimated the annual per-resident cost to be $58,025, $42,853, $35,894, and $33,574 for similar resident complements. Fixed costs mandated by the program requirements, which did not vary across program size or configuration, were estimated to be $640,737. CONCLUSIONS: There are fixed and variable costs associated with sponsorship of accredited internal medicine residency programs. The minimum cost per resident of education and departmental administration varies inversely with program size within the sizes examined.

Physicians' perceptions of the changing health care system: comparisons by gender and specialties.

This study was designed to investigate physicians' perceptions of changes in the United States health care system impacting academic medicine, quality of care, patient referrals, cost, ethical and sociopolitical aspects of medicine. A survey was mailed in 1998 to 1,272 physicians (graduates of Jefferson Medical (College between 1987 and 1992); 835 physicians (66%) responded. Results showed that a substantial majority (92%) believed that learning to work in a managed care environment should become an essential component of medical education. Physicians perceived that current changes impair physicians' autonomy (94%), and restrain physicians' freedom to provide optimal care (84%). A sizable majority (76%) endorsed patients' freedom to seek specialist care, and 55% believed that capitation reduces physicians' motivation for long-term monitoring of patients. The majority endorsed universal health coverage (80%), and agreed to support rather than resist the changes (62%). Only 18% hold a positive view of the changes in the future. The majority believed that medical education should prepare physicians to provide end-of-life care (92%), and that organized medicine should take a stand on social issues that can influence the well-being of society (79%). Only 34% endorsed the legalization of physician-assisted suicide. No gender differences were observed, but a few differences were found between generalists and specialists. Results can help in understanding physicians' perceptions of current changes in the United States health care system, and in providing guidelines for the development of educational programs to prepare physicians to face new challenges.

A comparison of the personality profiles of internal medicine residents, physician role models, and the general population.

PURPOSE: To compare personality profiles of internal medicine residents with those of the general population and positive role models in medicine. METHOD: A widely used personality inventory, NEO PI-R, which measures five major personality factors and 30 important personality facets, was administered in 1998 to 104 physicians in internal medicine residency and earlier to a nationwide sample of 188 physicians selected as positive role models in medicine. RESULTS: The internal medicine residents, compared with the general population, were more likely to be attentive, to have deeper intellectual curiosity, to have higher aspiration levels, to have more vivid imaginations, to be more receptive to their emotions, to be interested in mental stimulation, and to think carefully before acting. The residents, compared with role models in medicine, were less eager to face challenges, less able to control their impulses, less able to cope with adversity, less easygoing, and less relaxed, but were more likely to crave excitement. CONCLUSION: Internal medicine residents and positive role models in medicine have some distinct personal qualities. Understanding the qualities of successful physicians can be helpful in career counseling of medical students and young physicians.

The use of recombinant human erythropoietin in predialysis patients.

Recombinant human erythropoietin is increasingly used to treat anemia in predialysis patients. Approximately 33-40% of patients ultimately receiving dialysis or a transplant may be eligible for treatment, thus increasing the costs. Clinical trials demonstrate no significant alteration in the progression of renal disease, secondary to changes in systemic hemodynamics or blood volume, provided that blood pressure is controlled. Hypertension results from changes in viscosity and erythrocyte fluidity, loss of hypoxic vasodilatation, and changes in blood volume. The predialysis patient treated with recombinant human erythropoietin is likely to need aggressive antihypertensive therapy and vigorous diuresis. Cardiac output remains unchanged in the absence of blood volume expansion. The effects on left ventricular hypertrophy, left ventricular volume, or exercise-induced ischemic electrocardiographic changes in predialysis have not been studied systematically. Doses of recombinant human erythropoietin in predialysis patients tend to be lower when administered subcutaneously rather than intravenously, but the comparative cost-effectiveness of different dosing strategies is currently unknown. The dosing frequency can vary from three times a week to twice a month. The effect of anemia correction on the 'rehabilitation' of predialysis patients remains to be addressed.

Physician manpower reform: an analysis of the effects of the COGME Fourth Report on internal medicine residency positions. Council on Graduate Medical Education.

PURPOSE: To quantitate the impact of the recommendations contained in the Council on Graduate Medical Education (COGME) Fourth Report on the position distribution in internal medicine residency and fellowship programs and to recommend alternative position allocations for discussion. DATA SOURCES: The COGME Fourth Report, the National Study of Internal Medicine Manpower, and the American Medical Association Annual Survey of Graduate Medical Education. RESULTS: Our analysis of the COGME Fourth Report indicates that internal medicine PGY-1 positions would decrease from the 8,936 on duty in the 1992 academic year to 6,533 (-26.9%) for the class of the year 2000. Four thousand will enter generalist careers in internal medicine (approximately a 70% increase over current generalist output). The COGME Fourth Report recommendations would allocate first-year fellowship positions for 1,400 graduates of internal medicine residencies (-63.1%). Career-bound internal medicine positions will decrease from approximately 6,000 to 5,400 (-10.0%). The loss in PGY-1 positions is predominantly due to a decrease in the number of preliminary medicine positions and to individuals who switch from career-bound internal medicine positions to other disciplines after the PGY-1 or PGY-2 years. Pediatric positions would increase moderately from 2,426 available in 1993 to 2,520 (+3.9%). Pediatric subspecialty positions would decrease by 25% to 420, with 2,100 residents entering careers in general pediatrics. Family medicine PGY-1 positions would increase from the 2,657 available in 1993 to 3,400 (+28%). CONCLUSIONS: The recommendations contained in the COGME Fourth Report would substantially reduce the number, and significantly alter the current distribution, of residency positions. The output goals of 50% generalist careers are met by an increase in career-bound generalist positions in all three generalist specialties. The limitation of total positions to the goal of 110% of 1993 U.S. graduates comes predominantly through reduction of specialty/subspecialty career-bound positions. Internal medicine residency and subspecialty fellowship positions and programs would be significantly altered by these recommendations. The reductions in internal medicine occur predominantly in loss of positions not currently destined for careers in internal medicine and in subspecialty fellowship positions. These reductions are partially offset by an increase in the complement of residents who are destined for careers in general internal medicine.

A method for chronic membrane plasmapheresis in the rat.

Therapeutic apheresis as applied to humans may encompass a single treatment or numerous treatments for disorders ranging from acute poisoning to severe chronic autoimmune disease. However, the mechanisms of beneficial effects of apheresis are not well characterized. Utilizing a miniaturized hollow-fiber membrane system, we have developed a reliable technique for long-term vascular access in the rat that permits repetitive plasmapheresis. We established vascular access in 14 animals, with 8 and 6 rats randomized to 3- and 7-wk experimental periods, respectively. Immunoglobulin levels of blood samples obtained immediately before and after each plasmapheresis were measured to examine membrane filtration characteristics. Overall, 100% of the animals survived and 93% successfully completed their assigned experimental periods. Mean decrease of immunoglobulin G and M levels for 28 plasmapheresis treatments in five rats was 66.9 +/- 8.1 and 61.0 +/- 7.3% (SD), respectively, indicating effective membrane filtration. This model of apheresis can be applied to several disorders in the rat, including, but not limited to, spontaneous insulin-dependent diabetes mellitus and experimental inflammatory bowel disease.

Antibody response to pneumococcal polysaccharide vaccine in myasthenia gravis: effect of therapeutic plasmapheresis.

The removal of specific antibody in experimental animals has been reported to result in a subsequent increase in antibody to levels equal to (rebound) or exceeding those existing prior to removal (overshoot). Anecdotal reports suggest that rebound antibody synthesis after plasmapheresis may occur in humans with autoimmune disorders. We measured the antibody response to 12 pneumococcal polysaccharide antigens in patients with myasthenia gravis (MG) receiving a variety of therapies in order to determine whether the T-cell-independent IgG response to these antigens was augmented by plasmapheresis. MG patients receiving no immunotherapy or receiving prednisone had pre- and post-immunization titers similar to those of control patients. MG patients receiving prednisone and chronic plasmapheresis had higher pre-immunization titers than did other patient groups and had significantly higher post-immunization titers against multiple pneumococcal serogroups. Aggregate post-immunization geometric mean titers were more than three-fold higher in the plasmapheresis group as compared with other MG treatment groups. Enhancement of antibody response by plasmapheresis was abolished by the concomitant administration of azathioprine. Antibody rebound and overshoot after antibody removal may have important implications for the therapy of immune disorders by plasmapheresis.

Staphylococcal carriage and infection in myasthenia gravis patients receiving therapeutic apheresis.

Populations exposed to repetitive needle puncture (such as hemodialysis patients, insulin-dependent diabetics, and parenteral drug abusers) are at increased risk for nasal carriage of Staphylococcus aureus. These groups appear to have increased susceptibility to serious staphylococcal infection as well. We performed a microbiologic survey on a group of patients receiving regular, long-term therapeutic apheresis for myasthenia gravis (MG), and compared the rate of nasal staphylococcal carriage with that found in control groups of MG patients not receiving apheresis and ambulatory general medical patients without known risk factors for staphylococcal carriage. Medical records were reviewed for episodes of significant staphylococcal infection occurring since commencement of apheresis. Nasal S. aureus carriage was found in 9/29 (31%) apheresis patients, 8/30 (27%) MG controls, and 8/30 (27%) general medical controls. No significant difference in frequency of apheresis was noted between carriers and noncarriers. A single episode of S. aureus bacteremia occurred in 95 patient-years of apheresis therapy. We conclude that therapeutic apheresis for MG does not increase the risk of staphylococcal carriage, and that serious infection is infrequent.

Effect of acute hypercapnia on renal bicarbonate reabsorption in the dog.

The increased plasma bicarbonate concentration seen in hypercapnia implies that tubular bicarbonate reabsorption must be increased in the presence of an elevated Paco2. In contrast to early reports, more recent experimental data in acute hypercapnia have been interpreted to show that the observed increment in tubular reabsorption of bicarbonate factored for glomerular filtration rate (THCO3/GFR) is largely related to the concurrent changes in renal sodium reabsorption and to the increment in the filtered load of bicarbonate, and that acute hypercapnia per se causes little or no change in the tubular handling of bicarbonate. We reexamined this question by observing the changes in renal function occurring in the presence of a moderate elevation of plasma bicarbonate concentration in two groups of dogs. In group I, the elevation occurred as a result of acute hypercapnia during the administration of an "isometric" solution; in group II, it was caused by the infusion of identical amounts of an isotonic solution with the same concentration of sodium as in group I, but a higher bicarbonate concentration, in the presence of eucapnia. A subset of group II provided controls for the decrease in renal perfusion pressure that occurred spontaneously in group I. With increasing filtered loads of bicarbonate, fractional excretion (FE) of HCO3 increased in group II, whereas it dropped markedly in group I. Furthermore, the relative reabsorption rate of HCO3 compared with that of Cl (assessed by changes in fractional reabsorption (FR) of HCO3/Cl) decreased in group II, whereas it increased in group I. Although FENa also decreased in group II, the opposite changes in FR(HCO3/Cl) could not be attributed solely to concurrent changes in sodium handling, indicating that in the presence of acute hypercapnia there is a preferential reabsorption of bicarbonate that tends to perpetuate the increase in plasma bicarbonate concentration. By contrast, THCO3/GFR rose in both groups. The data are interpreted to reveal that acute hypercapnia, although causing a drop in renal perfusion pressure and in natriuresis, also has an additional specific effect on raising preferential bicarbonate reabsorption. This effect can be detected best by monitoring changes in the anionic composition of tubular reabsorbate, whereas it may not be unveiled by following changes in THCO3/GFR. Changes in THCO3/GFR may not yield useful information regarding the integrated response of the kidney to acid-base perturbations, and the conclusions of previous studies based on changes in this parameter must be carefully reexamined.