The faculty experience with the "troublesome" family practice resident.

BACKGROUND: Some family practice residents, by virtue of their behavior, generate discomfort, anger, and ambivalence in their supervising colleagues. These residents are labeled "troublesome." The purpose of this qualitative research was to identify and conceptualize characteristics of troublesome residents. METHODS: We retrospectively reviewed written evaluations of four residents who, out of a total of 111 residents in our program over five years, had been labeled "troublesome." Using the approach of constant comparisons, we identified a conceptual framework that described the troublesome residents. RESULTS: We were able to classify the comments in the residents' written evaluations into three categories. The first category was troublesome residents' discomforting behaviors. These included affronting, avoiding responsibility, and lack of initiative. The second category included ways in which the resident failed to meet faculty and program expectations, often manifest as lack of collaboration and commitment. The third category of comments involved the process of recognizing and dealing with the troublesome resident. This occurred in a three-stage process involving recognition, confrontation, and remediation. CONCLUSIONS: The classification of troublesome residents' performances into conceptual categories may be useful for helping faculty understand and deal with these learners.

Working with the difficult patient.

Patients who evoke emotional reactions in the family physician tend to be labelled "difficult". The difficult patient might be one who "yes . . . but" 's every suggestion, or who demands that the physician provide something inappropriate, like drugs or an unjustifiable letter. Whenever such an interaction occurs, the family physician can expect aggravation, frustration and, often, anger, and the results are likely to be unsatisfactory for both doctor and patient. This article describes an approach which will help the doctor to decide what actually to say or do in response to a difficult patient, especially within the time frame of the short office visit.

Breast-feeding and the Working Mother.

Despite the resurgent popularity and known benefits of breast-feeding, most Canadian women do not consider the possibility of continuing breast-feeding when they return to work. This paper examines the reasons why many women make this choice, and what factors are involved in continuing to breast-feed. The long-range goal of our society should be to increase the percentage of mothers who continue to breast-feed their babies until at least six months of age, and to increase the percentage of places of employment where it is possible for an employee to continue to breast-feed after returning to work.

Sexual assault tracking study: who gets lost to follow-up?

OBJECTIVES: To determine whether loss to follow-up can be predicted in patients who present to an emergency sexual assault assessment service and to generate hypotheses regarding the prediction of loss to follow-up on the basis of patient characteristics, assault characteristics and the services provided. DESIGN: Prospective, exploratory study. SETTING: Emergency department functioning as a regional sexual assault centre in a tertiary care hospital. PATIENTS: All 294 women over the age of 16 years who presented to the emergency department with a complaint of sexual assault and consented to be followed up. INTERVENTIONS: Telephone interviews at 24 to 48 hours and 1 month after presentation; face-to-face interviews after 1 week, 3 months and 6 months. MAIN OUTCOME MEASURES: Follow-up status (tracked versus lost to follow-up), State-Trait Anxiety Inventory (STAI-Y), Beck Depression Scale (Beck) and Rape Trauma Symptom Rating Scale (RTSRS). RESULTS: At 24 to 48 hours 136 (46%) of the patients could not be reached. Only 61 (21%) were still tracked at 6 months. Loss to follow-up at 1 month accurately predicted loss to follow-up at 6 months in 209 (98%) of 214 patients. For tracked patients the STAI-Y and Beck scores improved over 6 months. These scores at 1 week did not predict follow-up status at 6 months, but the numbers were small. Subjects with a higher RTSRS score at 24 to 48 hours were most likely to remain tracked throughout the 6 months. CONCLUSIONS: Decisions regarding how vigorously to track patients with a complaint of sexual assault can tentatively be based on the characteristics of the victim and of the assault. We hypothesize that the characteristics predicting loss to follow-up include denial and avoidance behaviour, lack of a telephone number or forwarding address, history of a psychiatric condition, a disability (e.g., deafness), characterization as a "street person," a high degree of violence or injury in the assault, and threat by the assailant. Although a predictive model requires further data, crisis intervention services in an emergency department are essential, given the large number of patients lost to follow-up.

Haida perspectives on living with non-insulin-dependent diabetes.

OBJECTIVE: To understand the experience of Haida people living with non-insulin-dependent diabetes mellitus (NIDDM), in order to provide a basis for a culturally sensitive community-based approach to managing NIDDM. DESIGN: Qualitative study using grounded theory. SETTING: The villages of Skidegate and Old Massett in Haida Gwaii (Queen Charlotte Islands), British Columbia. PARTICIPANTS: Nine focus groups met at the beginning and six at the end of the project. The focus groups had 8 to 12 members each and roughly the same number of men and women overall. The groups included people with diabetes, family members of people with diabetes, community leaders and elders. FINDINGS: Conceptual findings related to the participants' views on the impact of NIDDM on their lives, their views on what life was like before the effects of NIDDM were felt and their beliefs about the prevention and treatment of NIDDM. Six themes recurred in the discussions: fear; grief and loss; the loss of and desire to regain control; food and eating; physical and personal strength; and traditional ways. CONCLUSIONS: Insights into the illness experience of different cultural groups can inform program development and the creation of culturally sensitive health care interventions.