Donald A. Bloch, MD: a remembrance.

When someone dies, the world, or at least a representative portion of it, should stop, take note, weep, give thanks, and then measure the influence of that life on those it has touched so that moving forward is made more meaningful. This article takes a moment to remember Donald A. Bloch, MD. Bloch was a visionary and an innovator who chose collaboration as his primary methodology for creating change. He introduced us to the "dual optic," in which "Dr. Biomedicine" and "Dr. Psychosocial" work hand in hand with the patient and family. In addition to being a visionary, Don was an "architect/urban planner", who helped build communities and coalitions that promoted new ideas and championed novel initiatives. He was one of the founders of Family Systems Medicine (now Families, Systems, and Health), which is the field's vanguard journal.

Does practice make perfect? A randomized control trial of behavioral rehearsal on suicide prevention gatekeeper skills.

Suicide is the third leading cause of death among 10-24-year-olds and the target of school-based prevention efforts. Gatekeeper training, a broadly disseminated prevention strategy, has been found to enhance participant knowledge and attitudes about intervening with distressed youth. Although the goal of training is the development of gatekeeper skills to intervene with at-risk youth, the impact on skills and use of training is less known. Brief gatekeeper training programs are largely educational and do not employ active learning strategies such as behavioral rehearsal through role play practice to assist skill development. In this study, we compare gatekeeper training as usual with training plus brief behavioral rehearsal (i.e., role play practice) on a variety of learning outcomes after training and at follow-up for 91 school staff and 56 parents in a school community. We found few differences between school staff and parent participants. Both training conditions resulted in enhanced knowledge and attitudes, and almost all participants spread gatekeeper training information to others in their network. Rigorous standardized patient and observational methods showed behavioral rehearsal with role play practice resulted in higher total gatekeeper skill scores immediately after training and at follow-up. Both conditions, however, showed decrements at follow-up. Strategies to strengthen and maintain gatekeeper skills over time are discussed.

Physician self-disclosure in primary care visits: enough about you, what about me?

BACKGROUND: The value of physician self-disclosure (MD-SD) in creating successful patient-physician partnerships has not been demonstrated. METHODS: To describe antecedents, delivery, and effects of MD-SD in primary care visits, we conducted a descriptive study using sequence analysis of transcripts of 113 unannounced, undetected, standardized patient visits to primary care physicians. Our main outcome measures were the number of MD-SDs per visit; number of visits with MD-SDs; word count; antecedents, timing, and effect of MD-SD on subsequent physician and patient communication; content and focus of MD-SD. RESULTS: The MD-SDs included discussion of personal emotions and experiences, families and/or relationships, professional descriptions, and personal experiences with the patient's diagnosis. Seventy-three MD-SDs were identified in 38 (34%) of 113 visits. Ten MD-SDs (14%) were a response to a patient question. Forty-four (60%) followed patient symptoms, family, or feelings; 29 (40%) were unrelated. Only 29 encounters (21%) returned to the patient topic preceding the disclosure. Most MD-SDs (n=62; 85%) were not considered useful to the patient by the research team. Eight MD-SDs (11%) were coded as disruptive. CONCLUSIONS: Practicing primary care physicians disclosed information about themselves or their families in 34% of new visits with unannounced, undetected, standardized patients. There was no evidence of positive effect of MD-SDs; some appeared disruptive. Primary care physicians should consider when self-disclosing whether other behaviors such as empathy might accomplish their goals more effectively.

Depression, perceived family criticism, and functional status among older, primary-care patients.

OBJECTIVE: Relatively little research has examined the role of family factors in later-life depression, particularly in the broad range of depressive conditions seen in primary care. Authors tested the hypotheses that 1) perceived family criticism is independently associated with depression, 2) that family criticism and depression are independently associated with functional disability, and 3) that perceived family criticism moderates the association between depression and functional disability. METHODS: This cross-sectional study recruited 379 adults age > or =65 years from primary-care practices. Study measures included the Structured Clinical Interview for DSM-IV, the Hamilton Rating Scale for Depression, the Family Emotional Involvement and Criticism Scale, and several measures of functional disability. Multiple regression determined independent associations, and a multiplicative interaction term tested the moderator model of the third hypothesis. RESULTS: Perceived family criticism was independently associated with depression diagnosis and depressive symptoms. Depression diagnosis, depressive symptoms, and perceived family criticism were each independently associated with functional status. Perceived family criticism did not moderate the association between depressive symptoms and functional status in the overall study group, although it did moderate the association between depression diagnosis and instrumental activities of daily living when only early-onset depressed patients were included. CONCLUSIONS: Authors confirmed the first and second hypotheses; however data did not support the third hypothesis. These results provide support for clinicians to attend to quality of primary family relationships and perceived criticism in depressed older adults and for researchers to consider aspects of family functioning as covariates or potential targets for intervention studies.

Physician responses to ambiguous patient symptoms.

OBJECTIVE: To examine how primary care physicians respond to ambiguous patient symptom presentations. DESIGN: Observational study, using thematic analysis within a larger cross-sectional study employing standardized patients (SPs), to describe physician responses to ambiguous patient symptoms and patterns of physician-patient interaction. SETTING: Community-based primary care offices within a metropolitan area. PARTICIPANTS: Twenty-three primary care physicians (internists and family physicians). METHOD: Participating physicians had 2 unannounced SP visits randomly inserted into their daily practice schedules and the visits were audiotaped and transcribed. A coding system focusing on physician responses to concerned patients presenting with ambiguous symptoms was developed through an inductive process. Thematic analyses were then applied to coded data. RESULTS: Physicians' responses to ambiguous symptoms were categorized into 2 primary patterns: high partnering (HP) and usual care (UC). HP was characterized by greater responsiveness to patients' expression of concern, positivity, sensitivity to patients' clues about life circumstances, greater acknowledgment of symptom ambiguity, and solicitation of patients' perspectives on their problems. UC was characterized by denial of ambiguity and less inclusion of patients' perspectives on their symptoms. Neither HP physicians nor UC physicians actively included patients in treatment planning. CONCLUSIONS: Primary care physicians respond to ambiguity by either ignoring the ambiguity and becoming more directive (UC) or, less often, by acknowledging the ambiguity and attempting to explore symptoms and patient concerns in more detail (HP). Future areas of study could address whether physicians can learn HP behaviors and whether HP behaviors positively affect health outcomes.

The family experience of "sudden health": the case of intractable epilepsy.

This article reports the experience of "sudden health" among six families who participated in an exploratory qualitative study of families with a member who elects to have corrective surgery for intractable epilepsy. Families were interviewed pre- and post-surgery (6-8 months) and the interviews were analyzed using a constant comparative methodology. Findings indicated that (1) families were organized in two primary ways (nesting and crisis) to deal with epilepsy and the aftermath of surgery and (2) "sudden health" had differing effects on these families depending on their organizational style, emotional communication process, and developmental dynamics.