Physician recognition of behavioral, psychological, and social aspects of medical care.

Recognition of house officers of easily detectable medication noncompliance, psychiatric disturbances, and recent stressful life events was assessed by means of a structured interview with each patient immediately following the clinic visit, a physician questionnaire, and chart review. The study included 235 patients and 58 interns and residents in internal medicine. Although the house officers were informed of the intent of the study and had their performance reviewed weekly, they failed to recognize 79% of the underconsumption of regular medications, 34% of psychiatric disturbances, and 76% of patients' recent stressful events. Possible explantations for their failures to recognize these behavioral, psychological, and social factors include lack of awareness of their importance, lack of time and skills necessary for their identification, and inability to manage these problems. None of these explantations, however, adequately justifies such results.

Improvement in physicians' counseling of patients with mental health problems.

This study evaluated the impact of two interventions: (1) detailed feedback about a patient's mental health problem and desires for specific mental health interventions, and (2) a counseling protocol on medical residents' management of patients with mental health problems. These patients were seen in either a control, feedback, or feedback/protocol clinic. Immediately following their medical visit we found the following differences between feedback and control patients: feedback patients reported that the stress counseling they received was more valuable, and they were more satisfied with their physician; feedback patients also perceived greater decreases in the amount of overall stress experienced, and reported greater increases in their perceived control over stress. There were no outcome differences between feedback and feedback/protocol patients. We conclude that the feedback provided in this study can enhance physicians' ability to counsel primary care patients with mental health problems.

Identifying patients with depression in the primary care setting: a more efficient method.

OBJECTIVE: To determine if there is a core subset of depressive symptoms that could be used to efficiently diagnose depression after administering the 2-item PRIME-MD a screening questionnaire for depression. METHODS: One thousand patients selected randomly and by convenience from 4 primary care clinics were assessed by PRIME-MD and completed a questionnaire measuring the following validation variables: functional status and well-being, disability days, somatic symptoms, depression severity, suicidal thoughts, health care utilization, and the physician-patient relationship. RESULTS: Four symptoms (sleep disturbance, anhedonia, low self-esteem, and decreased appetite) accounted for virtually all the depression symptom-related variance in functional status and well-being, with 8.3% of patients having 2 of these symptoms and 8.2% having 3 or 4 of these symptoms. There was excellent agreement between diagnosis based on core symptoms and major depression (K= 0.77; overall accuracy rate, 94%). There were significant differences (P<.001) among patients with negative depression screen, 0 to 1, 2, and 3 to 4 core symptoms with scores on each of the validation variables getting progressively worse in these 4 groups. A cutoff point of 2 core symptoms identified all but 3 patients with major depression and an additional 5% of the entire sample without major depression who were significantly (P<.05) worse than patients without depression on each of the validation variables. CONCLUSION: A strategy that includes the use of a 2-item depression screener followed by the evaluation of 4 core depressive symptoms is an efficient and effective way of identifying and classifying primary care patients with depression in need of clinical attention.

Identifying hypertensive patients with elevated systolic workplace blood pressures.

The present study was designed to identify patients who had systolic work blood pressures that were substantially higher than their clinic blood pressures. Fifty-two mild and moderate hypertensive patients were assessed using clinic blood pressures and ambulatory blood pressure monitoring in their natural environment. Thirty-eight percent of these patients had systolic work blood pressures that were more than 10 mm Hg above their clinic blood pressures. These patients did not differ from other patients in terms of the demographic or clinical factors which were assessed. Need for control and anger, two core features of the Type A Coronary-prone Behavior Pattern, were shown to discriminate these patients on a statistically reliable basis. Research on cardiovascular reactivity to stress suggests that such patients with elevated systolic work blood pressures may be at greater risk for cardiac morbidity and mortality.

Coping style in hypertensive patients: nature and consequences.

Examined the coping styles and health behaviors of hypertensive and normotensive patients visiting a primary care setting for acute medical problems. Hypertensive individuals were far more likely to display a "high-monitoring" (information-seeking) mode of coping than normotensive individuals, who tended to be "low monitoring" (information avoiding) in their coping. Although hypertensive patients reported less dysfunction in their current medical problems than did normotensive patients, they nonetheless reported greater concerns about their condition and its impact. Finally, hypertensive patients were rated by physicians as more likely to desire help with both their presenting medical problem and their stress-related problems. Future research should help to specify the exact relations among coping style, stress, and symptom reporting in hypertension.

Recognizing and managing depression in primary care.

Depression is a common disorder in the primary care setting; it is associated with considerable distress and dysfunction. The management of depressed primary care patients can be complicated by the fact that these patients may lack insight into the cause of their symptoms and report only the somatic manifestations of their disorder to their physicians. Primary care patients may also be reluctant to accept a diagnosis of depression or referral to a mental health specialist. Primary care physicians may feel they lack the time or the training to adequately address their patients' depressive disorders. This paper presents a model for identifying, evaluating, and treating depression which has been specifically developed to help primary care physicians overcome these barriers.

Styles of coping with threat: implications for health.

We explored individual differences in health-seeking behavior and health status in a primary care population. Specifically, we compared high monitors (those who typically scan for threat-relevant information) with low monitors (those who typically ignore threat-relevant information), while controlling for depression. Overall, high monitors came to the physician with less severe medical problems than did low monitors. Nevertheless, high monitors reported equivalent levels of discomfort, dysfunction, and distress compared with low monitors. Furthermore, during the week following their visit, high monitors expressed less symptom improvement in both physical and psychological problems than did low monitors. Finally, high monitors demanded more tests, information, and counseling during their visit than did their low monitoring counterparts, yet desired a less active role in their own care. The theoretical and practical implications of these findings are discussed.

Automating psychiatric tasks: taking quality to the next level.

Advances in information technology have allowed the creation of databases and decision support systems for behavioral health care as well as other areas of medicine. The authors describe the state of the art in automating behavioral health care tasks and how automated information analyses provided in real time can measurably improve patient outcomes.

Primary care and the de facto mental health care system: improving care where it counts.

Only 28% of individuals suffering from psychiatric disorders seek care from mental health specialists. In this paper, the authors describe how the de facto PCP mental health care system gained ground when it seemed the financing and organizational structure of managed care would have predicted the opposite result. They argue that the new realities of mental health practice require new approaches to improving behavioral health treatment. These approaches, they believe, will maximize the benefit of care delivered in and accessed through the primary care office.

The patient's role in clinical decision-making.

Practicing physicians must frequently make decisions about how much they wish to encourage patient participation in clinical decision-making and how to respond to rational patient demands that do not coincide with their own decisions. These are difficult ethical dilemmas with no indisputable or universal solutions. The traditional concept of the doctor-patient relationship places the patient in a passive, compliant role. The patient's only obligation is to seek competent help and cooperate with the physician. A number of factors have contributed to the continued dominance of the traditional doctor-patient imbalance of power. Despite these factors, there seems to be a great deal of public dissatisfaction with health care delivery in the United States; demands for more patient autonomy are increasing. This paper discusses the concept of mutual participation, presents an approach to encouraging patient participation in clinical decision-making, and considers its theoretical advantages.

Feedback from patients as a means of teaching nontechnological aspects of medical care.

Despite an increased awareness of the importance of behavioral, psychological, and social aspects of medical care, physicians frequently fail to recognize problems in these areas. Therefore, a project was undertaken to improve house officers' recognition of these problems in an ambulatory population. An interviewer used a structured questionnaire to assess the patients' adherence to the therapeutic regimen, satisfaction with physician, psychiatric problems, recent stressful life events, and attitude toward illness. Recognition of medication noncompliance, psychiatric problems, and recent stressful life events was determined from a physician questionnaire and chart review for every patient interviewed. At the first clinic seesion after the interview, the author reviewed both the patient and physician questionnaires with the appropriate physician. The interviews identified a large number of potentially important problems which the patients' physicians had not recognized. While no change in problem recognition could be documented between the questionnaires administered at the beginning and end of the project, the vast majority of participating house officers felt that the project was worthwhile and should be continued.

Psychological distress and hypertension control.

Ninety-nine hypertensive patients who had been on antihypertensive therapies for at least six months because of diastolic blood pressure of 105 mg Hg or more were interviewed immediately after seeing their physicians. A four-item scale was used to separate those exhibiting the highest amount of psychological distress (18 patients) from the remainder of the group (81 patients). Patients exhibiting the greatest amount of psychological distress had smaller reductions in diastolic blood pressures and were more likely to have resistant hypertension (diastolic blood pressure greater than or equal to 100 mm Hg) at the next follow-up visit. This study suggests that a relationship exists between psychologic distress and hypertension control. Possibilities for future research are discussed.

Illness concerns and recovery from a URI.

Fifty ambulatory upper respiratory tract infection patients were studied to evaluate the nature of their illness concerns and explore the relationship between these concerns and subsequent recovery. Thirty-four patients still had URI-related symptoms 1 week after their medical visit, whereas 16 were asymptomatic. In general, asymptomatic patients could not be distinguished from symptomatic patients in terms of demographic variables, symptom type or duration, initial level of health concerns, physician findings, culture results, or therapy. Further, both groups exhibited surprisingly high levels of initial concern. Asymptomatic patients had a significantly greater reduction in these concerns shortly after their visit than the symptomatic group (P less than 0.01). Asymptomatic patients also reported more benefit from discussion of their concerns (P less than 0.01) and more satisfaction with this aspect of their care than the symptomatic group (P less than 0.001). The notion of illness concerns appears to be a concept worthy of clinical consideration and further investigation.

Patients' perspectives on the management of emotional distress in primary care settings.

OBJECTIVE: To investigate how important treatment for emotional distress is to primary care patients in general and to primary care patients with depression, and to evaluate the types of mental health interventions they desire. DESIGN: Patient surveys. SETTING: Five private primary care practices. MEASUREMENTS AND MAIN RESULTS: Patients' desire for treatment of emotional distress and for specific types of mental health interventions were measured, as well as patients' ratings of the impact of emotional distress, the frequency of depressive symptoms, and mental health functioning. Of the 403 patients, 33% felt that it was "somewhat important" and 30% thought it was "extremely important" that their physician tries to help them with their emotional distress. Patient desire for this help was significantly related to a diagnosis of depression (p < .001), perceptions about the impact of emotional distress (p < .001), and mental health functioning (p < .001). Among patients with presumptive diagnoses of major and minor depression, 84% and 79%, respectively, felt that it was at least somewhat important that they receive this help from their physician. Sixty-one percent of all primary care patients surveyed and 69% of depressed patients desired counseling: 23% of all patients and 33% of depressed patients wanted a medication: and 11% of all patients and 5% of depressed patients desired a referral to a mental health specialist. CONCLUSIONS: A majority of these primary care patients and almost all of the depressed patients felt that it was at least somewhat important to receive help from their physician for emotional distress. The desire for this help seems to be related to the severity of the mental health problem. Most of the patients wanted counseling, but relatively few desired a referral to a mental health specialist.

The depression in primary care tool kit.

OBJECTIVE: A tool kit was developed to help primary care physicians overcome some of the barriers to recognition and management of depression. METHOD: Tools were collected from a variety of sources, categorized by function, and evaluated on the basis of previously established criteria, with the best tools selected for inclusion in the tool kit. New tools were developed when an adequate tool for a desired function was not available. The tool kit was reviewed and then revised based on the feedback from eleven experts on depression in primary care, five medical directors from health care systems or managed care companies, and eighteen primary care physicians. All eighteen primary care physicians completed a questionnaire after reviewing the tool kit as part of the evaluation process. RESULTS: Only five of the eighteen physicians were using any kind of tool for depression prior to reviewing the tool kit. All eighteen physicians indicated that they were likely to use one or more of the components of the tool kit. On average, physicians indicated they were likely to use 6.5 of the ten types of tools included in the kit. CONCLUSIONS: A depression tool kit containing screening, diagnostic, management planning, and outcomes assessment questionnaires as well as treatment and counseling guidelines, information tables, flow charts, and patient education materials is likely to be well received by primary care physicians. However, its effectiveness may have as much to do with how its use is organized and implemented as it does with the intrinsic value of its components.

Viral transduction of c-myc gene in naturally occurring feline leukaemias.

Feline leukaemia virus (FeLV) is epidemiologically associated with induction of the majority of lymphoid tumours of the domestic cat. However, about one-third of these tumours are devoid of exogenous virus or show evidence of virus integration only after tumour outgrowth. To help define the genetic mechanisms of feline lymphomagenesis we have explored here the possibility that cellular oncogenes (c-onc genes) are rearranged in tumour cell DNA. Of 16 FeLV-positive T-cell tumours among 31 naturally occurring lymphomas, 2 showed evidence of recombinant FeLV proviruses containing myc oncogene sequences. One of the two produced a transmissible myc-containing FeLV. In both cases c-myc and its surrounding DNA appeared unaltered. We believe that the association of myc with FeLV may result in its activation and play a part in the development of a significant fraction of cat T-cell lymphomas. Our findings contrast with studies of experimental induction of chicken lymphoma, in which myc activation occurs by retrovirus promoter insertion near c-myc (refs 3-5), rather than by incorporation into virus.

The relationship between patients' satisfaction with their physicians and perceptions about interventions they desired and received.

This study was designed to determine the relationship between patients' satisfaction with their physician, the types of interventions that patients reported they received, and the congruence between those interventions and the types of interventions they desired. One hundred eighteen symptomatic adult primary-care patients completed questionnaires before and after their respective medical visits. Patients who indicated they received any one of the three nontechnical interventions: education (P less than 0.001), stress counseling (P less than 0.05), and negotiation (P less than 0.01), were significantly more satisfied than those who had not received these interventions. Patient perceptions about receiving technical interventions, i.e., examination, tests, medications, and nondrug therapy, were not related to patient satisfaction. The congruence between patient-intervention desires and perceptions about interventions received generally were not significantly related to satisfaction except for the interaction between receiving a medication and postvisit-medication desires (P less than 0.001). A series of multiple regression analyses revealed that, in general, perceptions about nontechnical interventions were better predictors of patient satisfaction than perceptions about technical interventions.

Patient perception of involvement in medical care: relationship to illness attitudes and outcomes.

OBJECTIVE: The purpose of this study was to explore the relationships among patients' perceptions about the roles they played during medical visits, their subsequent attitudes about their illnesses and treatments, and their self-rated improvement. DESIGN: Questionnaires were completed by patients before, one day after, and one week after their medical visits, and by their physicians following the visits. SETTING: The study was conducted in a general internal medicine faculty practice that provided adult primary care to a largely HMO population. PARTICIPANTS: Adult patients with new or increased symptoms who were capable of reading and understanding the study questionnaire. MAIN RESULTS: Fifty-five patients (47%) reported playing an active role; 62 patients (53%) reported playing a passive role. After adjusting for age, sex, baseline illness ratings, and physician-rated prognosis, "active" patients reported less discomfort (p = 0.04), greater alleviation of symptoms (p = 0.008), and more improvement in their general medical condition (p = 0.04) one week after the visits than did "passive" patients. These differences were not influenced by the roles patients desired to play. Active patients also reported less concern with their illnesses (p = 0.04), a greater sense of control of their illnesses (p = 0.04), and more satisfaction with their physicians (p = 0.02) one day after the visit. Post-visit dysfunction ratings were not related to patients' role perceptions. CONCLUSIONS: Patients' perceptions about their involvement in care appeared to be related to their attitudes about their illnesses as well as to recovery. Further research is needed, however, to determine the factors that influence these role perceptions and to define the types of patients, illnesses, and settings in which the benefits of active-role perceptions are most likely to be realized.

Patients' Perceived Involvement in Care Scale: relationship to attitudes about illness and medical care.

This report describes the development of the Perceived Involvement in Care Scale (PICS), a self-report questionnaire for patients, and its relation to primary care patients' attitudes regarding their illnesses and the management of them. The questionnaire was administered to three independent samples of adult primary care patients. Patients' satisfaction and their attitudes regarding their illnesses are evaluated after their medical visits. This instrument is designed to examine three relatively distinct factors: 1) doctor facilitation of patient involvement, 2) level of information exchange, and 3) patient participation in decision making. Of these factors, doctor facilitation and patient decision making were related significantly to patients' satisfaction with care. Doctor facilitation and information exchange related consistently to patients' perceptions of post-visit changes in their understanding, reassurance, perceived control over illness, and expectations for improvement in functioning. The role of physicians in enhancing patient involvement in care and the potential therapeutic benefits of physician facilitative behavior are addressed.

The white-coat hypertension response: prevalence and predictors.

This study was designed to determine the clinical characteristics of hypertensive patients whose blood pressures are substantially higher in the medical office than in their natural environments. Thirty-nine percent of patients enrolled in a nonpharmacologic hypertension treatment program had systolic or diastolic office blood pressures (OBPs) that were at least 10 mm Hg higher than their ambulatory blood pressures (ABPs). Although these white-coat responders (WCRs) had higher systolic OBPs than did non-white-coat responders (NRs), both their systolic (p less than 0.02) and their diastolic (p less than 0.0001) ABPs were significantly lower than those of NRs. Furthermore, patients with white-coat hypertension did not have greater blood pressure reactivity in their natural environments, suggesting that their blood pressure elevations may be specific to the medical setting. White-coat hypertensives were older (p less than 0.005), had less angry dispositions (p less than 0.01), and reported less overt anger expression (p less than 0.005). They were also taking more antihypertensive medications than were the other patients in the study (p less than 0.001).