Stressful life events and impulsiveness in failed suicide.

The relationship of recent stressful life events with impulsiveness in triggering suicide attempts and how impulsiveness changes from one suicide attempt to another is unclear. This study used structured-interview tools and standardized measurements to examine the relationship between life stress and impulsiveness in a sample of patients who required hospitalization for a medically serious suicide attempt. After controlling for potentially confounding variables, the number of disrupted interpersonal relationships in the preceding year was a significant predictor of the impulsiveness of the suicide attempt, with three or more losses (but not other life stresses) associated with less impulsive attempts (T = 2.4, p = .02). Female gender (T = -1.98, p = .05) and lifetime DMS-III-R diagnoses (T = -2.45, p = .02) were significantly associated with more impulsive attempts. In 55 patients with at least two suicide attempts, impulsiveness, lethal intent, and communication of intent were significantly greater for the present compared to the prior attempt (p = 0.000). Certain stressful life events, gender, and total lifetime DSM-III-R diagnoses are associated with impulsiveness of failed suicide attempts; yet, impulsiveness is not necessarily consistent from one suicide attempt to another. This evidence supports and amplifies a stress-diathesis model of suicide behavior. Accordingly, efforts to increase personal resilience in individuals who have "failed suicide" may be more effective at preventing suicide morbidity than simple stress-reduction measures alone.

Does continuity of care increase HMO patients' satisfaction with physician performance?

BACKGROUND: This study describes the relation between patient satisfaction with physician performance and seeing one's "own doctor" for a recent office visit. METHODS: A cross-sectional, randomized, computer-assisted telephone interview survey was performed at an urban health maintenance organization; 1146 responses were analyzed. RESULTS: Patients seeing their own physicians were significantly more satisfied than patients seeing another physician, even after controlling for effects of patient age, sex, reason for visit, clinic attended, satisfaction with appointment making, and interval between scheduling and making the visit. The interaction between getting one's choice of provider and seeing one's own physician was a significant predictor of satisfaction (P = 0.003). Among patients who got their choice of provider, seeing one's own physician had a more significant effect on satisfaction than seeing any other physician (P = 0.0009 compared with P = 0.04). Patients who did not receive their choice of provider but who did see their own physician had the highest satisfaction scores (P = 0.007). CONCLUSION: To increase patient satisfaction with physician performance, health maintenance organizations should ensure that patients see their "own doctor" whenever possible for routine office visits.

HMO family physicians: men and women differ in their work.

OBJECTIVE: The goal was to identify differences in the type of work and amount of work performed by male and female family HMO physicians. DESIGN: Data were collected by self-administered physician surveys, retrospective analysis of encounter forms, ambulatory care group (ACG) analysis of physicians' patient panels, and participant observation. SETTING: A large HMO-based clinical facility. PARTICIPANTS. Family practitioners (n = 21) at one HMO clinic. MAIN OUTCOME MEASURES: Measures included patient encounters/day, self-assessed and encounter-form-based workload, ambulatory care group panel evaluation and qualitative observation of practice patterns and team functioning. RESULTS: These data show that the kind of work male and female physicians did at this site differed, when compared on the basis of encounter-form-based diagnoses, ambulatory care group panel assessments and participant observation. However, the amount of work performed by each gender did not appear to different when evaluated by age-sex-adjusted panel size, patient encounters per unit time, a subjective magnitude estimation workload questionnaire and an encounter-form-based workload assessment. CONCLUSION: In this study, multiple measures for evaluating physician workload revealed distinct differences in the kind of clinical work performed by male and female HMO family physicians. These findings have implications for clinicians, managers, planners, researchers and educators.

The role of physicians' personal knowledge of the patient in clinical practice.

BACKGROUND: Primary care physicians' personal knowledge of their established patients has not been investigated systematically, and its role in clinical practice has not been characterized empirically. METHODS: A qualitative study used an iterative, grounded theory method for thematic analysis of transcribed, semistructured long interviews. Subjects were family physicians in stable employment and in continuous clinical practice for at least 2 years at a staff-model health maintenance organization. RESULTS: Personal knowledge of the patient clearly influenced the use of time in the examination room, the recognition of changes in baseline status, and the ability to verbalize medical information in terms that have unique meaning for particular patients. Personal knowledge fostered a sense of predictability in personal interactions; facilitated the creation of trust; served as an organizing scheme for data collection, recall, and interpretation; counterbalanced impersonal professional principles such as compulsiveness, duty, and responsibility; shaped ability to communicate effectively about issues related to quality of life and functional status; influenced choices of consultants; but also had the potential to interfere with diagnosis or with patient presentation of new information. CONCLUSIONS: Personal knowledge of patients was an important influence on physicians' daily clinical practice in this setting.

The personal knowledge of family physicians for their patients.

The physician-patient relationship has always been of interest to family physicians. This paper describes a component of the physician-patient relationship in family medicine, originally identified by Michael Balint, that operates parallel to and in conjunction with the biopsychosocial model: the family physician's personal knowledge of patients. The physician's personal knowledge of patients is a personal information network about particular patients who the physician has cared for over a series of encounters spanning several years. It is a detailed portrait painted with layers of fact, intuition, and experience and is comprised of a mix of clinical art, science, psychodynamics, and ethics. It may be factual, intuitive, or contain components of countertransference; it differs from Kleinman's concept of explanatory model in that it belongs to the physician and is employed for the benefit of the patient. It is neither paternalistic nor static. The family physician's personal knowledge for his or her patients is a seldom-measured but common component of the process of making medical, ethical, and pragmatic patient care decisions. The presence of this knowledge and its skillful use may mark one difference between novice and seasoned clinicians. Qualitative methods are most appropriate for exploring the breadth and depth of this concept, while quantitative methods are useful for studying its implications for clinical decision making and quality of care in family practice.

Patient sex role and preference for a male or female physician.

A study was undertaken to test whether a patient's sex role, as measured by the Bem Sex Role Inventory, is associated with preference for a male or female physician. One hundred ninety-three patients completed a physician preference survey and the Bem Sex Role Inventory. Thirty-six percent of patients preferred a physician of a specific sex. For women, sex role was associated with preference for a female physician (chi 2 = 16.14, P less than .01). Women with an androgynous sex role who gave a preference always chose a female physician; three fourths of women with an undifferentiated sex role who gave a preference always chose a female physician. Regardless of sex role, men who gave a preference always chose a male physician. For women, these findings support the hypothesis that sex role is associated with preference for a female physician.

The decision to see the physician: a clinical investigation.

To study why people decide to see a physician, 150 consecutive patient-initiated visits to a university family medicine center were evaluated prospectively. Physician and patient agreed about the reason for the decision to see a physician in 40 percent of encounters. Correlation was stronger for visits for health maintenance and weaker when patients were told to come, had psychosocial reasons, or experienced an event triggering their decision. An empirically based taxonomy of eight reasons for the decision to see a physician is presented: symptom existence causing pain (eg, cystitis), symptom existence causing anxiety (eg, child with fever), symptom persistence causing pain (eg, pharyngitis), symptom persistence causing anxiety (eg, skin rash), health maintenance visit, psychosocial reason, told to come, trigger event. Patients with psychosocial reasons presented ostensibly with symptom existence, symptom persistence, or health maintenance needs. Patients who were told to come were either unwilling to seek care or unable to interpret their symptoms appropriately. Two thirds of patients decided themselves to see a physician; one third consulted someone else; no one used books or the media to help decide.