Family caregiver descriptions of stopping chemotherapy and end-of-life transitions.

PURPOSE: The purpose of this study was to describe family caregivers' perspectives of the final month of life of patients with advanced cancer, particularly whether and how chemotherapy was discontinued and the effect of clinical decision-making on family caregivers' perceptions of the patient's experience of care at the end of life (EOL). METHODS: Qualitative descriptive design using semi-structured interviews collected from 92 family caregivers of patients with end-stage cancer enrolled in a randomized clinical trial. We used a phased approach to data analysis including open coding, focused coding, and within and across analyses. RESULTS: We identified three patterns of transitions characterizing the shift away from active cancer treatment: (1) "We Pretty Much Knew," characterized by explicit discussions about EOL care, seemingly shared understanding about prognosis and seamless transitions from disease-oriented treatment to comfort-oriented care, (2) "Beating the Odds," characterized by explicit discussions about disease-directed treatment and EOL care options, but no shared understanding about prognosis and often chaotic transitions to EOL care, and (3) "Left to Die," characterized by no recall of EOL discussions with transitions to EOL occurring in crisis. CONCLUSIONS: As communication and palliative care interventions continue to develop to improve care for patients with advanced cancer, it is imperative that we take into account the different patterns of transition and their unique patient and caregiver needs near the end of life. Our findings reveal considerable, and potentially unwarranted, variation in transitions from active treatment to death.

Pudor, honor, and autoridad: the evolving patient-physician relationship in Spain.

The expression of emotion and the sharing of information are determined by cultural factors, consultation time, and the structure of the health care system. Two emblematic situations in Spain - the expression of aggression in the patient-physician encounter, and the withholding of diagnostic information from the patient - have not been well-described in their sociocultural context. To explore these, the authors observed and participated in clinical practice and teaching in several settings throughout Spain and analyzed field notes using qualitative methods. In this paper, we explore three central constructs - modesty (pudor), dignity (honor), and authority (autoridad) - and their expressions in patient-physician encounters. We define two types of emotions in clinical settings - public, extroverted expressions of anger and exuberance; and private, deeply held feelings of fear and grief that tend to be expressed through the arts and religion. Premature reassurance and withholding of information are interpreted as attempts to reconstruct the honor and pudor of the patient. Physician authority and perceived loyalty to the government-run health care system generate conflict and aggression in the patient-physician relationship. These clinical behaviors are contextualized within cultural definitions of effective communication, an ideal patient-physician relationship, the role of the family, and ethical behavior. Despite agreement on the goals of medicine, the behavioral manifestations of empathy and caring in Spain contrast substantially with northern European and North American cultures.

New polyethylene glycol laxative for treatment of constipation in adults: a randomized, double-blind, placebo-controlled study.

BACKGROUND: This study evaluated the safety and effectiveness of a new polyethylene glycol (PEG) laxative (MiraLax, Braintree Laboratories Inc, Braintree, Mass) in 23 patients reporting a history of constipation. METHODS: After a 7-day placebo control period, patients were randomized into a double crossover trial of placebo versus 17 g of PEG daily for 4 days. Patient maintained a stool diary. RESULTS: Daily ingestion of a 17 g dose of PEG increased mean daily bowel movement frequency to once per day by the last 7 days of the 14-day treatment period. This was a statistically significant improvement over placebo, which provided about 1 bowel movement every 2 days during the last week of therapy. Patient diary ratings of related subjective symptoms were improved with PEG treatment over placebo. Both investigator and patients rated PEG therapy superior to placebo. No clinically significant changes in blood chemistry, complete blood count (CBC), or urinalysis were observed. CONCLUSIONS: Daily therapy with 17 g of PEG laxative for 14 days resulted in a significant improvement in bowel movement frequency in constipated patients relative to placebo by the second week of treatment.

Improving physicians' HIV risk-assessment skills using announced and unannounced standardized patients.

OBJECTIVE: To evaluate feasibility and to validate a rating scale for two educational programs that use standardized patient-instructors (SPIs) in the office setting to improve physicians' HIV risk communication skills. DESIGN: Pilot randomized trial of announced and unannounced SPIs. PARTICIPANTS/SETTINGS: Twenty four primary care physicians in the Rochester, NY, area. MEASUREMENTS: The Rochester HIV Interview Rating Scale (RHIRS), HIV test ordering, physician satisfaction questionnaire. RESULTS: Physicians found the intervention useful, and predicted a positive effect on their future HIV-related communication. HIV test ordering and RHIRS scores increased similarly in both intervention groups. Announced SPI visits were more convenient and preferred by physicians. Cost for each SPI visit was $75. CONCLUSIONS: A brief office-based intervention using SPIs was feasible, well-accepted, convenient, and inexpensive. Announced SPIs were preferred to unannounced SPIs. Pilot results suggesting improvement in HIV-related communication should be confirmed in a larger randomized trial.

Mindful practice.

Mindful practitioners attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. This critical self-reflection enables physicians to listen attentively to patients' distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so that they can act with compassion, technical competence, presence, and insight. Mindfulness informs all types of professionally relevant knowledge, including propositional facts, personal experiences, processes, and know-how, each of which may be tacit or explicit. Explicit knowledge is readily taught, accessible to awareness, quantifiable and easily translated into evidence-based guidelines. Tacit knowledge is usually learned during observation and practice, includes prior experiences, theories-in-action, and deeply held values, and is usually applied more inductively. Mindful practitioners use a variety of means to enhance their ability to engage in moment-to-moment self-monitoring, bring to consciousness their tacit personal knowledge and deeply held values, use peripheral vision and subsidiary awareness to become aware of new information and perspectives, and adopt curiosity in both ordinary and novel situations. In contrast, mindlessness may account for some deviations from professionalism and errors in judgment and technique. Although mindfulness cannot be taught explicitly, it can be modeled by mentors and cultivated in learners. As a link between relationship-centered care and evidence-based medicine, mindfulness should be considered a characteristic of good clinical practice.

Toward creating physician-healers: fostering medical students' self-awareness, personal growth, and well-being.

To restore the "humanism" in medical care, medical education needs to espouse the goal of creating physician-healers. Critical, and often neglected, factors in healing are the personal development and well-being of the healer. Unexamined attitudes and biases and personal stress can interfere with patient care. Personal awareness and well-being can contribute to physicians' using their emotional reactions to patients for their patients' benefit. The authors suggest goals and objectives for medical education that can promote trainees' self-awareness, personal growth, and well-being, and comment on how medical educators might achieve and evaluate these goals and objectives.

Somatization reconsidered: incorporating the patient's experience of illness.

The large and heterogeneous group of patients with "unexplained somatic symptoms," with or without coexisting psychiatric, "functional," or "organic" illnesses, provides continuing difficulty for clinicians. The construct of somatization artificially separates bodily and psychological symptoms that patients experience as a unified whole. Concurrent chronic illnesses make it difficult to exclude "general medical conditions." The diagnosis requires that the patient seek medical care. Conflict between patients' experiences of illness and physicians' diagnostic categories, and fear of blaming the patient, complicate naming and characterizing the illness. We recommend an approach to clinical care that involves exploring the patient's life context, finding mutually meaningful language to arrive at a name for the illness, normalizing the patient's bodily experience of distress, using a chronic disease model that attends to functioning, and addressing the physician's need for certainty and efficacy. Health systems can help coordinate care and avoid iatrogenic harm by appropriately controlling access to medical services.

Soliciting the patient's agenda: have we improved?

CONTEXT: Previous research indicates physicians frequently choose a patient problem to explore before determining the patient's full spectrum of concerns. OBJECTIVE: To examine the extent to which experienced family physicians in various practice settings elicit the agenda of concerns patients bring to the office. DESIGN: A cross-sectional survey using linguistic analysis of a convenience sample of 264 patient-physician interviews. SETTING AND PARTICIPANTS: Primary care offices of 29 board-certified family physicians practicing in rural Washington (n = 1; 3%), semirural Colorado (n = 20; 69%), and urban settings in the United States and Canada (n = 8; 27%). Nine participants had fellowship training in communication skills and family counseling. MAIN OUTCOME MEASURES: Patient-physician verbal interactions, including physician solicitations of patient concerns, rate of completion of patient responses, length of time for patient responses, and frequency of late-arising patient concerns. RESULTS: Physicians solicited patient concerns in 199 interviews (75.4%). Patients' initial statements of concerns were completed in 74 interviews (28.0%). Physicians redirected the patient's opening statement after a mean of 23.1 seconds. Patients allowed to complete their statement of concerns used only 6 seconds more on average than those who were redirected before completion of concerns. Late-arising concerns were more common when physicians did not solicit patient concerns during the interview (34.9% vs 14.9%). Fellowship-trained physicians were more likely to solicit patient concerns and allow patients to complete their initial statement of concerns (44% vs 22%). CONCLUSIONS: Physicians often redirect patients' initial descriptions of their concerns. Once redirected, the descriptions are rarely completed. Consequences of incomplete initial descriptions include late-arising concerns and missed opportunities to gather potentially important patient data. Soliciting the patient's agenda takes little time and can improve interview efficiency and yield increased data.

Talking about AIDS.

Despite increased public and professional awareness, patients and physicians tend to avoid discussions about HIV. Empiric studies of patient-physician communication point to specific common communication breakdowns. These include lack of a good opening line, inappropriate context, awkward moments, vague language, and a physician-centered rather than a patient-centered interview style. In effective HIV-related discussions, clinicians elicit the patient's beliefs and concerns first, are organized, use empathy, provide a rationale for the discussion, persist through awkward moments, and clarify vague language. In addition to information about sexual behaviors and the number, gender, and HIV status of partners, clinicians should ask about the context and antecedents to risk behaviors, praise prior attempts to reduce risk, and assess the patient's motivation to change. Although studies indicate that experienced practitioners often do not have these skills, they can be learned.

Awkward moments in patient-physician communication about HIV risk.

BACKGROUND: Physicians frequently encounter patients who are at risk for HIV infection, but they often evaluate risk behaviors ineffectively. OBJECTIVE: To describe the barriers to and facilitators of comprehensive HIV risk evaluation in primary care office visits. DESIGN: Qualitative thematic and sequential analysis of videotaped patient-physician discussions about HIV risk. Tapes were reviewed independently by physician and patient and were coded by the research team. SETTING: Physicians' offices. PARTICIPANTS: Convenience sample of 17 family physicians and general internists. Twenty-six consenting patients 18 to 45 years of age who indicated concern about or risks for HIV infection on a 10-item questionnaire administered before the physician visit were included. MEASUREMENTS: A thematic coding scheme and a five-level description of the depth of HIV-related discussion. RESULTS: In 73% of the encounters, physicians did not elicit enough information to characterize patients' HIV risk status. The outcome of HIV-related discussions was substantially influenced by the manner in which the physician introduced the topic, handled awkward moments, and dealt with problematic language and the extent to which the physician sought the patient's perspective. Feelings of ineffectiveness and strong emotions interfered with some physicians' ability to assess HIV risk. Physicians easily recognized problematic communication during reviews of their own videotapes. CONCLUSIONS: Comprehensive HIV risk discussions included providing a rationale for discussion, effectively negotiating awkward moments, repairing problematic language, persevering with the topic, eliciting the patient's perspective, responding to fears and expectations, and being empathic. Educational programs should use videotape review and should concentrate on physicians' personal reactions to discussing emotionally charged topics.

How students learn from community-based preceptors.

OBJECTIVE: To explore how students learn in community-based family physicians' offices from the student's point of view. METHOD: Each student completing a community-based family medicine clerkship wrote a "critical incident" narrative about an event that was particularly educational. A coding system was developed by a multidisciplinary research team and thematic analysis was conducted. RESULTS: Critical education experiences were brief, problem-focused, had definitive outcomes, were often collaborative, and led to self-reflection. The most commonly identified mode of learning was "active observation." In most of these situations, the student had significant clinical responsibility, but some involved observation of complex tasks beyond the expectations of a medical student. Most (77%) identified their learning needs after having observed a preceptor, rather than prospectively. Collaboration, coaching, advocacy, and exploring affect were means whereby preceptors and students created a learning environment that students felt was safe, allowed them to recognize their own learning needs, and helped them adopt new behaviors. CONCLUSIONS: These findings broaden the definition of active learning to include active observation and support learner-centered and relational models of learning. Increasing preceptors' awareness of these modes of student learning will enhance the quality of education in ambulatory settings.

Respiratory factors in the uptake and excretion of anesthetics. 1965.

We have considered some of the ways in which respiration can affect the gas exchange process. The simplest relationships are purely physical and relate to the speed with which the lung and tissues can be filled or emptied. More complex relationships involve a consideration of the interplay between blood and gas in the lung and the effects of gas exchange on respiratory volumes themselves. Finally, some examples of the importance of physiologic alteration produced by, and producing respiratory shifts during, gas uptake processes were presented briefly. The detailed interpretation of gas exchange phenomena demands more quantitative information of this sort, concerning not only the respiratory but the circulatory and tissue level variations affecting uptake during anesthesia. Nevertheless, understanding of the principles and application of such data as are available can go far toward removing the handicaps of empirical practice from the day-to-day administration of anesthetic agents to human beings.