The path to professionalism: cultivating humanistic values and attitudes in residency training.

Though few question the importance of incorporating professionalism and humanism in the training of physicians, traditional residency programs have given little direct attention to the processes by which professional and humanistic values, attitudes, and behaviors are cultivated. The authors discuss the underlying philosophy of their primary care internal medicine residency program, in which the development of professionalism and humanism is an explicit educational goal. They also describe the specific components of the program designed to create a learner-centered environment that supports the acquisition of professional values; these components include a communication-skills training program, challenging-case conferences, home visits with patients, a resident support group, and a mentoring program. The successful ten-year history of the program shows how a residency program can enable its trainees to develop not only the requisite excellent diagnostic and technical tools and skills but also the humane and professional attributes of the fully competent physician.

The meaning of symptoms in 10 women with somatization disorder and a history of childhood abuse.

OBJECTIVE: To understand the associated experiences and illness behavior in patients with somatization disorder and a history of childhood abuse. DESIGN: In-depth interviews were conducted with patients who had somatization disorder and a history of childhood abuse; qualitative content analysis was then performed. SETTING: Patients were recruited from 2 primary care teaching practices. PARTICIPANTS: Physicians were asked to refer patients suspected of having both conditions, yielding 21 potential participants. Eight declined, and 3 did not meet standardized screening questionnaire criteria, yielding 10 women who participated in the study. Participants and nonparticipants had a similar range of socioeconomic variables. RESULTS: An analysis of the interviews yielded 22 themes. Seven themes relevant to understanding the link between illness behavior and abuse were the abuse experiences, emotional and behavioral reactions to the abuse, relationship of abuse to somatoform symptoms, relationship of abuse to health care use, attempts to tell about the abuse, relationships with physicians, and physician behavior. Childhood attempts to tell adults about the abuse resulted in threats of punishment, contributing to lifelong patterns of secrecy, even with physicians. Six women reported having childhood physicians who were family members, friends, or the abuser's physician, reinforcing their subsequent secrecy. The women reported that their current physicians denied their physical pain as adults, just as the abusers denied their emotional and physical pain in childhood. Seven women reported decreased health care use once they associated symptoms with abuse experiences. Nine women reported spousal abuse. CONCLUSIONS: Somatization and childhood abuse may involve a paradoxical pattern of hiding feelings and reality, while seeking acknowledgment of suffering. Patient insight may decrease health care use. Therefore, the exploration of patient experiences may be useful for women with somatization disorder and a history of childhood abuse. The risks of spousal abuse and denial and rejection in the physician-patient relationship could also be important.

Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient.

Physicians' personal characteristics, their past experiences, values, attitudes, and biases can have important effects on communication with patients; being aware of these characteristics can enhance communication. Because medical training and continuing education programs rarely undertake an organized approach to promoting personal awareness, we propose a "curriculum" of 4 core topics for reflection and discussion. The topics are physicians' beliefs and attitudes, physicians' feelings and emotional responses in patient care, challenging clinical situations, and physician self-care. We present examples of organized activities that can promote physician personal awareness such as support groups, Balint groups, and discussions of meaningful experiences in medicine. Experience with these activities suggests that through enhancing personal awareness physicians can improve their clinical care and increase satisfaction with work, relationships, and themselves.

A model of empathic communication in the medical interview.

OBJECTIVE: To formulate an empirically derived model of empathic communication in medical interviews by describing the specific behaviors and patterns of interaction associated with verbal expressions of emotion. DESIGN: A descriptive, qualitative study of verbal exchanges using 11 transcripts and 12 videotapes of primary care office visits to a total of 21 physicians. SETTING: An urban health maintenence organization (HMO), an urban university-based general medicine clinic, and an urban community hospital general medicine clinic. ANALYTIC METHOD: Individual review of transcripts by each research team member to identify instances of expressed or implied emotional themes and to observe the physicians' responses. Individual ratings were compared in group discussions to achieve consensus about the classifications. Similar consensus-based classification was used for review of videotapes. RESULTS: We observed that patients seldom verbalize their emotions directly and spontaneously, tending to offer clues instead. If invited to elaborate, patients may then express the emotional concern directly, and the physician may respond with an accurate and explicit acknowledgment. In most of the interviews, the physicians allowed both clues and direct expressions of affect to pass without acknowledgment, returning instead to the preceding topic, usually the diagnostic exploration of symptoms. With emotional expression so terminated, some patients attempted to raise the topic again, sometimes repeatedly and with escalating intensity. We noted a parallel dynamic for encounters in which patients sought praise. We summarized the full interactional sequence in a simple descriptive model. CONCLUSIONS: This empirically derived model of empathic communication has practical implications for clinicians and students who want to improve their communication and relationship skills. Based on our observations, the basic empathic skills seem to be recognizing when emotions may be present but not directly expressed, inviting exploration of these unexpressed feelings, and effectively acknowledging these feelings so the patient feels understood. The frequent lack of acknowledgment by physicians of both direct and indirect expressions of affect poses a threat to the patient-physician relationship and warrants further study.

The doctor-patient relationship and malpractice. Lessons from plaintiff depositions.

BACKGROUND: The current literature does not provide an answer to the question, "What prompts patients to sue doctors or hospitals?" Not all adverse outcomes result in suits, and threatened suits do not always involve adverse outcomes. The exploration of other factors has been hampered by the lack of a methodology to contact plaintiffs and elicit their views about their experience in delivered health care. This study employed the transcripts of discovery depositions of plaintiffs as a source of insight into the issues that prompted individuals to file a malpractice claim. METHODS: This study is a descriptive series review of a convenience sample of 45 plaintiffs' depositions selected randomly from 67 depositions made available from settled malpractice suits filed between 1985 and 1987 against a large metropolitan medical center. Information extracted from each deposition included the alleged injury; the presence of the question, "Why are you suing?" and, if present, the answer; the presence of problematic relationship issues between providers and patients and/or families and, if present, the discourse supporting it; the presence of the question, "Did a health professional suggest maloccurrence?" and, if yes, who. Using a process of consensual validation, relationship issues were organized into groups of more generalized categories suggested by the data. Answers to the questions, "Why are you suing?" and "Who suggested maloccurrence?" are described. RESULTS: Problematic relationship issues were identified in 71% of the depositions with an interrater reliability of 93.3%. Four themes emerged from the descriptive review of the 3787 pages of transcript: deserting the patient (32%), devaluing patient and/or family views (29%), delivering information poorly (26%), and failing to understand the patient and/or family perspective (13%). Thirty-one plaintiffs were asked if health professionals suggested maloccurrence. Fifty-four percent (n = 17) responded affirmatively. The postoutcome-consulting specialist was named in 71% (n = 12) of the depositions in which maloccurrence was allegedly suggested. CONCLUSIONS: In our sample, the decision to litigate was often associated with a perceived lack of caring and/or collaboration in the delivery of health care. The issues identified included perceived unavailability, discounting patient and/or family concerns, poor delivery of information, and lack of understanding the patient and/or family perspective. Particular attention should be paid to the postadverse-event consultant-patient interaction.

Lack of demonstrated effect of nandrolone on serum lipids.

Numerous prior studies of serum lipid levels during anabolic steroid (AS) use have uniformly demonstrated dramatic adverse lipid profiles (eg, average high-density lipoprotein [HDL] depression of 50%) during administration of 17 alpha-alkylated AS. In contrast, the existing studies of 17 beta-esterified AS have shown mild or absent lipid effects (eg, HDL depression 0% to 16%) with these agents. Thus, the potential effects on serum lipids of individual AS are an important clinical consideration. The present study was therefore designed to investigate the lipid effects of nandrolone, a 17 beta-esterified AS. Twenty-one men and three women had lipid profiles measured before and after administration of nandrolone decanoate 100 mg intramuscularly (IM) once a week for 6 weeks. No significant change was noted in HDL cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol, triglycerides, the total cholesterol to HDL-C ratio, or the LDL-C/HDL-C ratio from nandrolone treatment. Moreover, observed trends toward HDL-C depression (-2.00 +/- 8.83 mg/dL; values reported are for men only unless noted otherwise) and LDL elevation (+5.05 +/- 20.45 mg/dL) were small. In power analysis, HDL-C depressions of 6.3, 7.6, or 8.7 mg/dL during nandrolone were ruled out with powers of 80%, 95%, and 99%, respectively.

Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy on Physician and Patient.

To study encounter-specific physician satisfaction we collected exit questionnaires from patients and physicians following 550 primary care office visits. The physicians' questionnaire included 20 items pertaining to satisfaction with the visit, one of which was an assessment of global satisfaction. Using a boot-strap technique, we factor analyzed the satisfaction questions in 10 repeated samples. Four distinct dimensions of physician satisfaction emerged: satisfaction with the patient-physician relationship, with the data collection process, with the appropriateness of the use of time, and with the absence of excessive demands on the part of the patient. Each scale was found to be reliable; global satisfaction was most closely related to the relationship factor. Satisfaction with use of time and the adequacy of data collection tended to be stable for individual physicians across a range of patients whereas global satisfaction and satisfaction with the relationship and the demanding nature of the patient and were more variable, hence most unique to each encounter. This study of physician satisfaction represents an effort to incorporate knowledge about physicians' subjective experiences into a systematic understanding of the dynamics of the medical interview.

Making "connexions": enhancing the therapeutic potential of patient-clinician relationships.

Healers must try to understand what the illness means to the patient and create a therapeutic sense of connection in the patient-clinician relationship. A favorable climate for "connexional" experiences can be created through the use of various interviewing techniques. Attending to rapport, silencing internal talk, accessing unconscious processes, and communicating understanding can help clinicians enhance their sensitivity to the subtle clues on which issues of meaning and connection often depend. Several risks are associated with the establishment of closer patient-clinician relationships, including dependence and power issues, sexual attraction, and deeper exposure of the clinician to the patient's pain. Prepared with an awareness of these risks and techniques to address them, clinicians are encouraged to deepen their level of dialogue with patients, to compare their experiences with those of other clinicians, and to thereby develop a more systematic understanding of therapeutic relationships.

Understanding fear of contagion among physicians who care for HIV patients.

BACKGROUND: Fear of contagion has been identified as a potential deterrent for primary care physicians who would otherwise care for HIV patients. This study examines physicians' fears of occupational HIV transmission and the ways that they cope with those fears. METHODS: Thirty community-based primary care physicians who were caring for HIV patients were interviewed about their experiences with HIV patients and the meanings they ascribe to those experiences. Qualitative content and narrative analysis were used. RESULTS: Fear of contagion was common despite the relatively low reported self-assessment of risk by primary care physicians. Most physicians considered their level of risk acceptable, but for some it seemed to take a high emotional toll. Some physicians identified their fear as "irrational." Physicians reported tension between fear of contagion and ethical responsibility to care for HIV patients. Some physicians were overattentive to infection control measures, whereas others used universal precautions inconsistently. Physicians continued to care for HIV patients despite their fears. Some physicians' family members needed information and reassurance about transmission of HIV. CONCLUSIONS: Some physicians who care for HIV patients are poorly equipped to deal with their own fears. There is a need to examine in greater depth the relationship between fear of contagion and willingness to provide care, and to examine other factors that may be contributing to the expression of these fears.

Primary care of patients with human immunodeficiency virus infection. The physician's perspective.

OBJECTIVE: To examine physicians' perceptions, motivations, and influences on their willingness to care for patients with human immunodeficiency virus (HIV). DESIGN: Interviews with 30 physicians. Qualitative content and narrative analyses were performed. SETTINGS: Community-based primary care practices in six moderate-sized cities in the northeastern United States with at least a moderate incidence or prevalence of reported acquired immunodeficiency syndrome cases. PARTICIPANTS: Thirty community-based primary care physicians who had cared for at least two patients with HIV during the previous 2 years. MAIN OUTCOME MEASURE: Qualitative study designed to provide rich descriptive data. RESULTS: Care of patients with HIV was regarded as part of the scope of primary care, and was perceived to be similar to the care of patients with other chronic illnesses. Many physicians were motivated by personal rewards in taking care of patients, intellectual challenge, and desire to serve the underserved. Most believed that practicing physicians have an ethical obligation to care for all patients, regardless of diagnosis. No one "type" of physician could be identified who provides care to patients with HIV. CONCLUSIONS: Primary care physicians can apply their skills in the management of other chronic diseases to the care of patients with HIV. Practicing physicians can find caring for patients with HIV rewarding, stimulating, and enjoyable. Educational programs for physicians need to emphasize psychosocial aspects of HIV care. In addition, physicians need opportunities to recognize and deal effectively with their own emotional responses to the care of patients with HIV.

Classic conditioning and placebo effects in crossover studies.

OBJECTIVE: To find evidence of classically conditioned placebo effects in a placebo-controlled crossover drug study. Specifically, we tested a prediction of the conditioning model that the placebo response will be greater after drug exposure than before. METHODS: Twenty-four patients with mild to moderate essential hypertension and no contraindications to atenolol participated in the study. The study design required randomized assignment to one of three groups: placebo followed by 50 mg atenolol daily, followed by no treatment, each for 1 week; atenolol followed by placebo; and atenolol followed by nothing (to show residual drug effects). Twice-daily blood pressure measurements were made by patients at home; once-weekly measurements of blood pressure and heart rate were made by a research nurse. RESULTS: Before drug treatment, there were no differences in the antihypertensive responses of patients taking placebo and patients taking nothing (difference, 0.98 mm Hg; 95% confidence interval, -0.98 to 2.93). After atenolol treatment, placebo treatment produced a significantly greater antihypertensive response than no treatment (difference, -6.09 mm Hg; 95% confidence interval, -11.81 to -0.38). Thus the placebo response after atenolol administration was more than a residual drug effect. Similar patterns were observed for heart rate but not for blood pressure readings taken in the office. CONCLUSIONS: These observations are consistent with a conditioning model of placebo effects. These findings warrant further investigation in larger studies and in other disease models.