Spousal suffering and partner's depression and cardiovascular disease: the Cardiovascular Health Study.

OBJECTIVES: To assess the effects of suffering in a spouse on prevalent and incident psychiatric (depression) and physical morbidity (cardiovascular disease [CVD]) in their partner, controlling for known risk factors for depression and CVD. DESIGN: Descriptive longitudinal study. PARTICIPANTS: A total of 1,330 older married couples enrolled in the Cardiovascular Health Study, a large epidemiologic study of the elderly. MEASUREMENTS: Predictor variables were physical, psychological, and existential/spiritual indicators of suffering. Primary outcomes were prevalent and incident depression and CVD. RESULTS: Controlling for known risk factors for depression, the authors found a dose-response relationship between suffering in a spouse and concurrent depression in their partner as well as a relationship between suffering and the partner's future risk for depression. With respect to CVD, and controlling for subclinical CVD at baseline, husbands whose wives reported high levels of suffering also had higher rates of prevalent CVD, but there were no significant associations between wives suffering and husbands incident CVD. There were no associations between husbands' suffering and wives' prevalent or incident CVD. CONCLUSION: Exposure to spousal suffering is an independent and unique source of distress in married couples that contributes to psychiatric and physical morbidity. More attention should be paid to the interpersonal effects of suffering in married couples and to its role in contributing to morbidity.

Dementia patient suffering and caregiver depression.

Cross-sectional and longitudinal analyses were carried out to assess the relationship between dementia patient suffering, caregiver depression, and antidepressant medication use in 1222 dementia patients and their caregivers. We assessed the prevalence of 2 types of patient suffering, emotional and existential distress, and examined their independent associations with caregiver depression and antidepressant medication use when controlling for sociodemographic characteristics of caregivers and patients, cognitive and physical disability of the patient, the frequency of patient memory problems and disruptive behaviors, and the amount of time spent caring for the patient. Multiple linear regression models showed that both aspects of perceived patient suffering independently contribute to caregiver depression (emotional distress: beta=1.24; P<0.001; existential distress: beta=0.66; P<0.01) whereas only existential suffering contributes to antidepressant medication use: odds ratio=1.25 95% confidence interval, 1.10-1.42; P<0.01. In longitudinal analyses, increases in both types of suffering were associated with increases in caregiver depression (emotional distress: beta=1.02; P<0.01; existential distress: beta=0.64; P<0.01). This is the first study to show in a large sample that perceived patient suffering independently contributes to family caregiver depression and medication use. Medical treatment of patients that maintain or improve memory but do not address suffering may have little impact on the caregiver. Alzheimer disease patient suffering should be systematically assessed and treated by clinicians.

Nurse Practitioners as Disruptive Innovators in Palliative Medicine.

As the population ages, the corresponding rise in people living with life-limiting illnesses will lead to a greater need for clinician experts in palliative medicine. There are not enough physicians available to care for the growing number of patients, however. We believe that nurse practitioners are well positioned to meet this demand. In this paper, we will use the concept of disruptive innovations to provide support for our belief that nurse practitioners can, and should, take a larger role in palliative medicine. First, we will describe how 2 general types of business models-solution shops and value-adding processes-can be applied to health care in general and palliative medicine specifically. Second, we will describe the concept of disruptive innovations. Finally, we will use these business models to explain how nurse practitioners are particularly well suited to disrupt the current business model of palliative medicine, thereby allowing more patients with life-limiting illness to receive the high-quality care they need.

Improving well-being in caregivers of terminally ill patients. Making the case for patient suffering as a focus for intervention research.

Family caregivers are integral to the care of patients with physical or mental impairments. Unfortunately, providing this care is often detrimental to the caregivers' health. As a result, in the last decade, there has been a proliferation of interventions designed to improve caregivers' well-being. Interventions for caregivers of persons at end of life, however, are relatively few in number and are often underdeveloped. They also are typically designed to help reduce the work of caregiving or to help caregivers cope with the physical and emotional demands of providing care. Although useful, these interventions generally ignore a primary stressor for family caregivers -- a loved one's suffering. Patient suffering, whether physical, psychosocial, or spiritual, has a major impact on family caregivers. However, interventions that focus on the relief of patient suffering as a way to improve caregiver well-being have rarely been tested. It is our view that more research in this area could lead to new and more effective interventions for family caregivers of seriously or terminally ill patients. In support of our view, we will define suffering and review the relationships between patient suffering and caregiver well-being. We will then discuss a conceptual framework for intervention design. Finally, we conclude with a discussion of implications and future directions for intervention research.

Patient suffering and caregiver compassion: new opportunities for research, practice, and policy.

The purpose of this article is to stimulate discussion and research about patient suffering and caregiver compassion. It is our view that these constructs are central to understanding phenomena such as family caregiving, and that recognizing their unique role in the caregiving experience provides new directions for intervention research, clinical practices, and social policy. We first define and characterize these constructs, review empirical evidence supporting the distinct role of suffering and compassion in the context of caregiving, and then present a conceptual model linking patient suffering with caregiver compassion. We conclude with a discussion of implications and future directions for clinical intervention, research, and policy.

Caregiving at the end of life.

This paper provides a review of family caregiving for adult patients with serious, lifethreatening illness. Areas covered include the (1) epidemiology of family caregiving, (2) cross-cultural issues in caregiving, (3) impact of caregiving on families, (4) similarities and differences involved in providing care for patients with various illnesses, and (5) interventions for family caregivers. The importance of family caregiving to palliative care practice is emphasized.

Preparedness for the death of a loved one and mental health in bereaved caregivers of patients with dementia: findings from the REACH study.

BACKGROUND: Although it has been suggested that family and friends who are prepared for the death of a loved one have less distress, the relationship between preparedness and bereavement mental health is inconclusive. OBJECTIVES: To determine the relationship between preparedness for the death and mental health in bereaved caregivers of dementia patients and explore predictors of preparedness. DESIGN: A prospective study of family caregivers of persons with dementia. Standardized assessment instruments and structured questions were used to collect data at study entry and at 6, 12, and 18 months. Multiple caregiving-related variables were collected. Bereaved caregivers reported whether they were "not at all" prepared or prepared for the death of their loved one. SUBJECTS: Two hundred twenty-two bereaved caregivers RESULTS: Twenty-three percent of caregivers were not prepared for the death. These caregivers had more depression, anxiety, and complicated grief symptoms. Black caregivers, caregivers with less education, those with less income, and those with more depressive symptoms prior to the death were more likely to perceive themselves as "not at all" prepared. In contrast, the amount of pain the care recipient was in prior to death was positively associated with preparedness. CONCLUSIONS: Despite providing high-intensity care, often for years, many bereaved caregivers perceived themselves as unprepared for the death. These caregivers had more depression, anxiety, and complicated grief symptoms. Future work should be directed to confirming these findings and determining how best to intervene with high-risk caregivers.

Preparing caregivers for the death of a loved one: a theoretical framework and suggestions for future research.

Caring for a terminally ill loved one and the death of that person are two of the most stressful human experiences. Recent research suggests that a substantial number of caregivers are unprepared for the death and that these caregivers may be at greater risk of psychological distress. The literature on preparedness and mental health, however, is in its infancy. The purpose of this paper, therefore, is to summarize the literature in order to stimulate discussion and research on preparedness. It is our view that preparedness for the death of a loved one is an important contributor to caregiver well-being and bereavement outcomes and that more work in this area is needed in order to improve the care provided to caregivers of seriously or terminally ill patients. We briefly review the literature on preparedness, present a theoretical model delineating the relationships between preparedness, caregiver-health care provider communication, and caregiver well-being, and provide suggestions for future research.

Caregiver intervention research: an opportunity for collaboration between caregiving investigators and African-american faith communities.

The African-American community in the United States is rapidly aging. Because friends and family who care for these elderly individuals often do so at the expense of their own physical and psychological well-being, there has been extensive interest in the development of interventions to reduce caregiver burden and morbidity. Few interventions, however, have targeted African-American caregivers. Given the importance of religion for many African-American caregivers, we believe that faith communities could be valuable allies to research investigators. The primary objectives of this paper, therefore, are to: 1) summarize the literature on religion and African-American caregivers; 2) provide a rationale for why caregiving investigators and African-American faith communities should collaborate; and 3) present directions for future research. We present evidence to support our assertion that, not only could collaboration result in interventions that improve the well-being of African-American caregivers, collaboration would also benefit both caregiving investigators and faith communities.

The Stanford Prison Experiment: Implications for the Care of the "Difficult" Patient.

Approximately 15% of patients are perceived by clinicians as "difficult." Early theories about difficult patients focused on patients' and clinicians' characteristics, often underemphasizing the influence of the environment on patients' behavior. The Stanford Prison Experiment, a classic experiment in the psychology of human behavior, provides a broader systems approach for understanding the environmental influences on patient behavior. A systems approach to the care of the difficult patient takes into consideration not only the patient's characteristics but also the health care environment and the more distal environments (ie, familial, societal, and cultural). Clinicians who are aware of the multilevel impact of these various environments on the behavior of patients are better equipped to understand, address, and hopefully even prevent difficult patient encounters.

Palliative Care Education in Nurse Practitioner Programs: A Survey of Academic Deans.

The need for clinicians trained in palliative care will increase as more Americans live with life-limiting illness. Although multiple studies have described the nature of palliative care education in prelicensure programs, there have been no similar studies of nurse practitioner programs. We surveyed 101 nurse practitioner programs. Most programs provide little instruction in palliative care; education is often limited to a few hours of lecture. One-third of programs offer no instruction. Although palliative care is an important component of advanced practice nursing practice, programs may not be providing adequate education.

Correlates of Family Satisfaction with Hospice Care: General Inpatient Hospice Care versus Routine Home Hospice Care.

BACKGROUND: The quality of communication and support provided to families is associated with greater satisfaction with hospice care. Prior work has not explored whether the predictors of family satisfaction are different in different hospice care settings. OBJECTIVE: The study objective was to explore whether correlates of family satisfaction are different in general inpatient hospice care versus routine home hospice care. METHODS: Survey data from bereaved family members of approximately 1600 patients from a nonprofit, midsized hospice in western Pennsylvania were used. Data was obtained from Family Evaluation of Hospice Care (FEHC) survey responses from 2008-2013 and separated into two groups, general inpatient hospice care and routine home hospice care. The analysis was completed using a binomial logistic regression model. RESULTS: Three variables were associated with greater overall satisfaction in both care settings: being kept informed about the patient's condition (adjusted odds ratio [AOR]: 9.64, CI: 6.56-14.36); being provided with clear/consistent information (AOR: 2.34, CI: 1.47-3.72); and the perception that patients were provided with adequate treatment for anxiety (AOR: 2.64, CI: 1.19-5.81). Two variables, sufficient discussion with hospice team members concerning family members' religious or spiritual beliefs (AOR: 1.64, CI: 1.17-2.30) and being provided with the correct amount of emotional support after the patient's death (AOR: 2.01, CI: 1.10-3.66), were correlated with greater satisfaction in routine home hospice care only. CONCLUSIONS: Good communication is strongly associated with greater family satisfaction across hospice care settings. Hospices must ensure that they provide patients and families with consistent information and support.

Resident research and scholarly activity in internal medicine residency training programs.

OBJECTIVES: 1) To describe how internal medicine residency programs fulfill the Accreditation Council for Graduate Medical Education (ACGME) scholarly activity training requirement including the current context of resident scholarly work, and 2) to compare findings between university and nonuniversity programs. DESIGN: Cross-sectional mailed survey. SETTING: ACGME-accredited internal medicine residency programs. PARTICIPANTS: Internal medicine residency program directors. MEASUREMENTS: Data were collected on 1) interpretation of the scholarly activity requirement, 2) support for resident scholarship, 3) scholarly activities of residents, 4) attitudes toward resident research, and 5) program characteristics. University and nonuniversity programs were compared. MAIN RESULTS: The response rate was 78%. Most residents completed a topic review with presentation (median, 100%) to fulfill the requirement. Residents at nonuniversity programs were more likely to complete case reports (median, 40% vs 25%; P=.04) and present at local or regional meetings (median, 25% vs 20%; P=.01), and were just as likely to conduct hypothesis-driven research (median, 20% vs 20%; P=.75) and present nationally (median, 10% vs 5%; P=.10) as residents at university programs. Nonuniversity programs were more likely to report lack of faculty mentors (61% vs 31%; P<.001) and resident interest (55% vs 40%; P=.01) as major barriers to resident scholarship. Programs support resident scholarship through research curricula (47%), funding (46%), and protected time (32%). CONCLUSIONS: Internal medicine residents complete a variety of projects to fulfill the scholarly activity requirement. Nonuniversity programs are doing as much as university programs in meeting the requirement and supporting resident scholarship despite reporting significant barriers.

Minimal prevalence of authorship misrepresentation among internal medicine residency applicants: do previous estimates of "misrepresentation" represent insufficient case finding?.

BACKGROUND: High rates of authorship misrepresentation have been documented among medical trainees. OBJECTIVE: To assess misrepresentation among internal medicine residency applicants while comparing searches used by previous authors (searches 1 and 2) to a more comprehensive strategy (search 3). DESIGN: Review of 497 residency applications. SETTING: Two university-based internal medicine residency programs. MEASUREMENTS: Search 1 was limited to MEDLINE. Search 2 added Current Contents, Science Citation Index, and BIOSIS and included searching journals by hand. Search 3 added seven other databases and contacts to librarians, editors, and coauthors. RESULTS: 224 applicants reported 634 articles; 630 (99%) were verified. The number of applicants with misrepresented citations varied depending on the search used (56 applicants [25%] in search 1 vs. 34 applicants [15%] in search 2 vs. 4 applicants [1.8%] in search 3). CONCLUSIONS: Using a comprehensive search, we found substantially less misrepresentation than had been reported. Previous studies probably overestimated the magnitude of the problem.

Re-examining the value of medical grand rounds.

PURPOSE: To study medical grand rounds, the cornerstone of a department of medicine's educational programs. METHOD: Between April and June 2001, a questionnaire was sent to chairs of departments of medicine at the 389 U.S. hospitals with medicine residency programs accredited by the Accreditation Council for Graduate Medical Education. Data were collected on the objectives and attendance, educational structure, perceived quality, and costs of medical grand rounds. RESULTS: Three hundred questionnaires were returned (77%). Grand rounds were offered by 97% of departments and accredited for continuing medical education in 96% of hospitals. The most important objectives were to educate, showcase faculty role models, and promote a collegial atmosphere. Patients were present at grand rounds less than 3% of the time. Grand rounds were predominantly lecture based; only 10% were clinical case presentations or interactive workshops/small groups, the formats proven most effective for facilitating adult learning and a humanistic approach to patients. Curricular tenets of needs assessment, program evaluation, and knowledge assessment were performed in only 73%, 59%, and 17% of programs, respectively. University hospitals were less likely to incorporate these principles (p <.01). Although respondents attested to the high quality of grand rounds, many potential attendees missed more than half the sessions. Grand rounds were the most expensive conference in 78% of departments, with the pharmaceutical industry providing the majority of the funding. CONCLUSIONS: Medical grand rounds are costly and often do not take into account learners' needs. Departments of medicine should reevaluate their commitment to grand rounds.

A systematic review of resident research curricula.

PURPOSE: To review in a systematic manner the published curricula for training house officers in research. METHOD: Articles were identified by searching the Medline, Educational Resources Information Center, and Science Citation Index databases, educational Web sites, and bibliographies of captured articles, and by contacting experts who had developed resident research curricula. Demographic information, curriculum development steps, educational strategies, evaluation methods, and outcomes were abstracted. RESULTS: The search identified 41 articles describing curricula. The most common curricular objectives were to increase house officers' research productivity and improve their critical appraisal skills. Only one curriculum was designed with the goal of producing academic physicians. Among many instructional methods, conducting research projects, exposing learners to role models or mentors, and providing house officers with multiple opportunities to present their work were common. Only 27 articles (66%) articulated goals or objectives, and 11 included (27%) needs assessments. Evaluation methods were often rudimentary, frequently limited to learners' self-assessments or authors' anecdotal reports. Five (12%) reported pre-post-intervention testing of learners' knowledge. No curricula were evaluated as prospective pretest-posttest controlled trials. A minority of articles reported costs, obstacles encountered, or modifications made in the curriculum. CONCLUSION: Successful educational interventions should incorporate needs assessments, clearly defined learning objectives, and evaluation methods. While many curricula for resident research exist, the lack of detailed developmental information and meaningful evaluations hinders educators interested in adopting these curricula.

Prominent medical journals often provide insufficient information to assess the validity of studies with negative results.

BACKGROUND: Physicians reading the medical literature attempt to determine whether research studies are valid. However, articles with negative results may not provide sufficient information to allow physicians to properly assess validity. METHODS: We analyzed all original research articles with negative results published in 1997 in the weekly journals BMJ, JAMA, Lancet, and New England Journal of Medicine as well as those published in the 1997 and 1998 issues of the bimonthly Annals of Internal Medicine (N = 234). Our primary objective was to quantify the proportion of studies with negative results that comment on power and present confidence intervals. Secondary outcomes were to quantify the proportion of these studies with a specified effect size and a defined primary outcome. Stratified analyses by study design were also performed. RESULTS: Only 30% of the articles with negative results comment on power. The reporting of power (range: 15%-52%) and confidence intervals (range: 55-81%) varied significantly among journals. Observational studies of etiology/risk factors addressed power less frequently (15%, 95% CI, 8-21%) than did clinical trials (56%, 95% CI, 46-67%, p < 0.001). While 87% of articles with power calculations specified an effect size the authors sought to detect, a minority gave a rationale for the effect size. Only half of the studies with negative results clearly defined a primary outcome. CONCLUSION: Prominent medical journals often provide insufficient information to assess the validity of studies with negative results.

Self-doctoring: a qualitative study of physicians with cancer.

BACKGROUND: Self-doctoring is providing oneself care normally delivered by a professional caregiver. Expert authors warn physicians not to self-doctor, yet cross-sectional studies document that physicians frequently do. Explanations for this disparity remain speculative. OBJECTIVE: To better understand the circumstances when physicians did and did not doctor themselves and the reasoning behind their actions. DESIGN: Qualitative semistructured interview study of 23 physician-patients currently or previously treated for cancer. RESULTS: Participants had multiple opportunities to doctor themselves (or not) at each stage of illness. Only 1 physician recommended self-doctoring, although most reported having done so, sometimes without realizing it. Participants' approaches to their own health care created a continuum ranging between typical physician and patient roles. Participants emphasizing their physician role approached their health care as they would approach the care of their own patients, preferring convenience and control of their care to support from professional caregivers. Participants emphasizing their role as patient approached their health care as they thought a patient should, preferring to rely less on their own abilities and more on their providers, whose support they valued. Most participants balanced both roles depending on their experiences and basic issues of trust and control. Importantly, subjects at both ends of the continuum reported unanticipated pitfalls of their approach. CONCLUSION: Our findings showed that participants' health care-seeking strategies fell on a continuum that ranged from a purely patient role to one that centered on physician activities. Participants identified problems associated with overdependence on either role, suggesting that a balanced approach, one that uses the advantages of both physician and patient roles, has merit.

Nurse practitioners and the growth of palliative medicine.

As Americans live longer they are likely to suffer from chronic, life-limiting illness. Because there are not enough hospice and palliative medicine (HPM) trained physicians to care for these people, there have been recent calls to increase the number of HPM trained physicians. We, however, believe that greater involvement of nurse practitioners (NPs) is a step in remedying this deficit. The philosophy and culture in which nurse practitioners are trained make them ideal clinicians to provide excellent palliative care. In addition, NPs are not only numerous, they can provide care that is on par with that provided by physicians. Removal of barriers to NP practice and increasing the quality of their palliative care education/training needs to occur in order to make this suggestion a reality.