'It just has to click': Internists' views of: what constitutes productive interactions with chronically ill patients.

BACKGROUND: According to the Chronic Care Model, productive interactions are crucial to patient outcomes. Despite productive interactions being at the heart of the Model, however, it is unclear what constitutes such an interaction. The aim of this study was to gain a better understanding of physician views of productive interactions with the chronically ill. METHOD: We conducted a qualitative study and interviewed 20 internists working in an academic hospital. The data were analyzed using a constructivist approach of grounded theory. To categorize the data, a coding process within which a code list was developed and tested with two other coders was conducted. RESULTS: The participants engaged in goal-directed reasoning when reflecting on productive interactions. This resulted in the identification of four goal orientations: (a) health outcome; (b) satisfaction; (c) medical process; and (d) collaboration. Collaboration appeared to be conditional for reaching medical process goals and ultimately health outcome and satisfaction goals. Achieving rapport with the patient ('clicking,' in the term of the participants) was found to be a key condition that catalyzed collaboration goals. Clicking appeared to be seen as a somewhat unpredictable phenomenon that might or might not emerge, which one had to accept and work with. Goal orientations were found to be related to the specific medical context (i.e., a participant's subspecialty and the nature of a patient's complaint). CONCLUSIONS: The participants viewed a productive interaction as essentially goal-directed, catalyzed by the two parties clicking, and dependent on the nature of a patient's complaint. Using the findings, we developed a conceptual process model with the four goal orientations as wheels and with clicking in the center as a flywheel. Because clicking was viewed as important, but somewhat unpredictable, teaching physicians how to click, while taking account of the medical context, may warrant greater attention.

Urinary excretion of histamine and some of its metabolites in man: influence of the diet.

Urinary excretions of histamine, N tau-methylhistamine and N tau-methylimidazoleacetic acid have been determined in 10 normal subjects on 3 different diets, containing a very low protein, a low protein and a high protein amount. Foodstuffs which could contain histamine were excluded. The mean excretion of N tau-methylhistamine on the second day of each diet amounted to 0.861 mumol/24 h, 1.051 mumol/24 h and 1.378 mumol/24 h, respectively. The excretions of histamine and N tau-methylimidazoleacetic acid were not affected. In 6 normal persons on a protein low diet, the excretions of histamine, N tau-methylhistamine and N tau-methylimidazoleacetic acid have been determined for 10 days. On the fifth day, to 3 persons 200 mumol of histamine was given orally, the other 3 persons received a high protein diet. The persons receiving histamine showed a strongly enhanced excretion of N tau-methylimidazoleacetic acid, corresponding to 36.1% of the administered histamine, whereas the urinary excretions of histamine and N tau-methylhistamine were only slightly elevated. On the high protein diet, only the excretion of N tau-methylhistamine was slightly elevated. The urinary excretions of histamine in the female subjects sometimes showed unexpectedly high values. Most probably, this phenomenon is attributable to bacterial histamine production in the urogenital tract.