Public reporting of surgical mortality: a survey of New York State cardiothoracic surgeons.

BACKGROUND: Public disclosure of individual surgeons mortality following coronary artery bypass (CAB) is part of the New York State Department of Health Cardiac Surgery Reporting System (CSRS). The effects on the practice of cardiac surgery, as perceived by surgeons, remain unknown. METHODS: All 150 New York State cardiac surgeons were sent an anonymous mail survey in 1997. Data was analyzed to determine the dominant opinion regarding the CSRS. RESULTS: One hundred and four surgeons (69.3%) responded. The majority (70%) did not experience a change in practice. Data reporting was performed by the surgeon or an employee (58%). Many picked the incorrect definition of chronic obstructive pulmonary disease (COPD) (45%) or statistical method (60%). The aspect of CSRS most in need of improvement was gaming with risk factors (40%). Most surgeons (62%) refused to operate on at least one high-risk CAB patient over the prior year, primarily because of public reporting. Refusal was more common in surgeons in practice less than 10 years, those with less than 100 cases per year, and those with a mixed cardiothoracic practice (p < 0.05, Pearson's chi2 test). A significantly higher percentage of high-risk CAB patients were treated non-operatively, when compared with ascending aortic dissection patients (not disclosed) (p < 0.001, Wilcoxon signed ranks test). CONCLUSIONS: The public disclosure of surgical results may be based on imperfect data and appears to have resulted in denial of surgical treatment to high-risk patients.

Studies in thoracic aortic graft infections: the development of a porcine model and a comparison of collagen-impregnated dacron grafts and cryopreserved allografts.

OBJECTIVE: A porcine model of thoracic aortic graft infection was created, and various anatomic sites and the timing of inoculation of the graft to induce infection were investigated. Ultimately, the ability of cryopreserved allograft to resist infection was compared with that of collagen-impregnated Dacron graft. METHODS: Yorkshire pigs (n = 16) underwent placement of an expanded polytetrafluoroethylene patch graft in the ascending aorta and the left atrial appendage (phase I). Eight animals were immediately given a 50-mL bolus (1 x 10(8) cfu/mL) of Staphylococcus aureus whereas the other 8 received the infusion 24 hours later. Animals were put to death 8 weeks later and the grafts were sterilely explanted and analyzed via microbiologic culture and standard histologic procedures for evidence of infection. The results displayed that the aortic graft and a delay of induced bacteremia of 24 hours were more reliable methods of producing infection. During phase II, 13 pigs were randomized to receive either a collagen-impregnated Dacron graft (n = 6) or a cryopreserved allograft (n = 7) in the ascending aortic position only and infusion of S aureus 24 hours after the operation. The experiment then proceeded to completion. RESULTS: Phase I results displayed that use of an aortic graft and induced bacteremia 24 hours after the operation was a more reliable and reproducible method of producing infection. In phase II, graft infection was present in 38.5% (5/13) of animals, with only 16.7% (1/6) in the collagen-impregnated Dacron graft group and 57.2% (4/7) in the cryopreserved allograft group becoming infected. There was no significant difference between the collagen-impregnated Dacron graft and cryopreserved allograft groups in the incidences of thoracic aortic graft infections (P =.27, Fisher exact test). CONCLUSIONS: This novel porcine model of thoracic aortic graft infection is a reproducible method for the investigation of thoracic aortic graft infections. The phase I study investigated the timing of the induced bacteremia and the most susceptible position of a graft. Phase II demonstrated that collagen-impregnated Dacron grafts are equivalent, if not superior, to cryopreserved allografts in resisting central vascular graft infections in the ascending aorta.

Teaching compassion and respect. Attending physicians' responses to problematic behaviors.

OBJECTIVE: To describe how and why attending physicians respond to learner behaviors that indicate negative attitudes toward patients. SETTING: Inpatient general internal medicine service of a university-affiliated public hospital. PARTICIPANTS: Four ward teams, each including an attending physician, a senior medicine resident, two interns, and up to three medical students. DESIGN: Teams were studied using participant observation of rounds (160 hours); in-depth semistructured interviews (n = 23); a structured task involving thinking aloud (n = 4, attending physicians); and patient chart review. Codes, themes, and hypotheses were identified from transcripts and field notes, and iteratively tested by blinded within-case and cross-case comparisons. MAIN RESULTS: Attending physicians identified three categories of potentially problematic behaviors: showing disrespect for patients, cutting corners, and outright hostility or rudeness. Attending physicians were rarely observed to respond to these problematic behaviors. When they did, they favored passive nonverbal gestures such as rigid posture, failing to smile, or remaining silent. Verbal responses included three techniques that avoided blaming learners: humor, referring to learners' self-interest, and medicalizing interpersonal issues. Attending physicians did not explicitly discuss attitudes, refer to moral or professional norms, "lay down the law," or call attention to their modeling, and rarely gave behavior-specific feedback. Reasons for not responding included lack of opportunity to observe interactions, sympathy for learner stress, and the unpleasantness, perceived ineffectiveness, and lack of professional reward for giving negative feedback. CONCLUSIONS: Because of uncertainty about appropriateness and effectiveness, attending physicians were reluctant to respond to perceived disrespect, uncaring, or hostility toward patients by members of their medical team. They tended to avoid, rationalize, or medicalize these behaviors, and to respond in ways that avoided moral language, did not address underlying attitudes, and left room for face-saving reinterpretations. Although these oblique techniques are sympathetically motivated, learners in stressful clinical environments may misinterpret, undervalue, or entirely fail to notice such subtle feedback.

"Making all the difference in the world": how physicians can help HIV-seropositive patients become more involved in their healthcare.

Physicians who treat HIV-seropositive patients can and should help them become more involved in their healthcare. This qualitative study investigated HIV-seropositive persons' perspectives regarding when and how physicians could have a pronounced effect on their involvement. Sixty-four HIV-seropositive patients, diverse in gender, ethnicity, and risk factors, were purposefully selected from three San Francisco Bay Area healthcare delivery settings. A combined interview-guide approach with a standardized open-ended interview was used to elicit participants' healthcare and physician relationship experiences. Data analysis revealed the themes that (1) involvement led to improved health outcomes and quality of life, (2) three life circumstances served as "opportune moments" for persons becoming more involved with their healthcare (a diagnosis of HIV/AIDS, the onset of symptoms, and beginning drug treatment intervention), and (3) participants became more involved when their physicians used a relationship-centered approach to healthcare. The results of the study suggest that physicians should be aware of opportune moments to intervene with their HIV-seropositive patients and of the helpful effect a personal, caring, relationship-centered approach can have on these individuals' involvement in their care. The recognition of opportune moments also may have implications for treating other chronic illnesses.

Education in ambulatory settings: developing valid measures of educational outcomes, and other research priorities.

Efforts to redesign education in ambulatory settings are hampered by a lack of rigorous and coherent research on the learning process in these settings and the desired outcomes of the educational experiences. The authors present 13 priority research topics and 51 important research questions concerning education in ambulatory settings that were defined by a distinguished group of medical educators, clinicians, and policymakers who attended an invitational conference on education in ambulatory settings in 1996. The need to establish valid and reliable measures of quality and outcomes of educational programs and instructional interventions stood out as the major prerequisite for conducting research on education in ambulatory settings. Issues of theory building, research priorities, and research design are discussed, and policy recommendations are made for the development of valid measures of educational outcomes. The creation of a "Medical Education Outcomes Commission" is proposed to act as a repository for measures and instruments, and to provide the field with mechanism to validate instruments and uniform recommendations to conduct studies of quality. The authors urge funding agencies with missions that support medical education to invest in basic research on the outcomes of education in ambulatory settings.

Provoking nonepileptic seizures: the ethics of deceptive diagnostic testing.

The use of deception in medical care is highly suspect in this country. Yet there is one condition for which deception is often used as a diagnostic tool. Nonepileptic seizures, a psychiatric condition in which emotional or psychological conflicts manifest themselves unconsciously through bodily symptoms, are currently diagnosed by a procedure called "provocative saline infusion." The test is fundamentally deceptive, requiring the physician to intentionally and directly lie to the patient, causing the patient to believe that the administered solution caused his seizures. Without such deception, the test might be useless.

A study of medical students' specialty-choice pathways: trying on possible selves.

PURPOSE: To describe the decision-making processes reported by graduating medical students in choosing primary care (PC) or non-primary-care (NPC) specialties. METHOD: Members of the University of Washington School of Medicine's graduating class of 1995 were invited to participate in focus groups. Six specialty-choice pathways were defined based on a previously administered survey of recalled preferences at matriculation and stated choice at the time of the National Resident Matching Program. Students were assigned to focus groups based on specialty-choice pathway. Transcribed discussions and summaries were thematically coded and analyzed using grounded theory and quantitative comparisons. RESULTS: Of 157 students, 140 (89%) completed the initial survey, and 133 (85%) provided enough information to be classified by pathway. In all, 47 students participated in the focus group discussions. The PC students cited PC orientation, diversity of patients and activities, role models and mentors, interaction with patients, and overall medical school culture as having influenced their choice. The NPC students cited lifestyle, controllable hours, opportunities to do procedures, therapeutic urgency and effect, active tempo, exciting settings, and intellectual challenge. Role models influenced PC career choice much more than NPC career choice, and often served to refute negative stereotypes. The sense of personal fit between themselves and specialties was important to the students in all groups, but differed in emphasis according to career-choice pathways. Those whose preferences did not change experienced a confirmation of pre-existing beliefs, while those who switched specialty areas developed a sense of fit through the inclusion or elimination of different practice aspects. Those who switched specialty areas reported more negative influences and misunderstanding of their initially preferred specialties. CONCLUSION: The process of specialty choice can be described usefully as a socially constructed process of "trying on possible selves" (i.e., projecting oneself into hypothetical career and personal roles). This may explain role models' exceptional influence in disproving negative stereotypes. Medical students' choices can best be facilitated by recognizing their needs to gain knowledge not only about specialty content, but also about practitioners' lives and the students' own present and possible selves.

Role models' perceptions of themselves and their influence on students' specialty choices.

PURPOSE: To examine the perceptions of faculty role models to learn whether their perceptions of role models' behaviors are congruent with those of their students. METHOD: In 1996 a survey was mailed to 210 student-identified faculty role models at the University of Washington School of Medicine and the University of North Carolina at Chapel Hill School of Medicine. The nominees were asked to rate to what extent each of 32 student-identified role model characteristics was representative of their behavior. They were then asked to rank order the characteristics they felt were most important to model for students. The role models were also asked to rate how much influence they perceived themselves to have on their students' specialty choices. A final, open-ended question inquired about the single characteristics they modeled to students that most influenced the students' specialty choices. The role models' specialties were grouped as either primary care (PC) or non-primary care (NPC). Data were analyzed with several statistical methods. RESULTS: Of the 210 mailed surveys, a total of 177 were returned, for a response rate of 84%. The role models perceived their behaviors much like their students did; the role models' self-ratings were generally high for all of the student-defined characteristics. Although clinical reasoning was considered the most important characteristic to model for students, the role models also believed that enthusiasm and love for their work were the characteristics that most influenced their students' specialty choices. Few differences were found between the PC and the NPC role models. CONCLUSION: The role models in this study agreed with their students about what is important to model. They did not intentionally try to recruit students to join their specialties but felt that demonstrating enthusiasm and a sincere love for what they did has a strong influence toward this end.

Combined carotid endarterectomy, innominate artery reconstruction, and coronary artery bypass grafting: case report.

Neurologic injury is one of the most devastating complications of combined carotid and cardiac procedures. Although the cause of the deficit is usually embolic, the exact cause is often not apparent at the time of surgery. We present a complex case of combined carotid endarterectomy, innominate artery reconstruction, and coronary artery bypass procedures in which intraoperative monitoring with somatosensory evoked potentials and transcranial Doppler ultrasonography combined with postoperative acetazolamide single photon emission computed tomographic scans was used to correlate intraoperative events with cerebral activity and functional results. Although computed tomographic scan, magnetic resonance imaging, and clinical evaluation were negative for any evidence of stroke, the patient exhibited subtle postoperative changes in neuropsychologic function. These changes were correlated with intraoperative microemboli detected by transcranial Doppler monitoring, and postoperative acetazolamide single photon emission computed tomographic scanning, which revealed bilateral cortical defects.

Pilot randomized controlled trial of Chinese herbal treatment for HIV-associated symptoms.

We wished to determine the short-term safety and efficacy of a Chinese medicinal herb preparation in treating symptoms of human immunodeficiency virus (HIV) infection in a 12-week randomized, double-blind, placebo-controlled clinical trial in a University-affiliated acquired immunodeficiency syndrome (AIDS) clinic at a public general hospital. Thirty adults with symptomatic HIV infection, no previous AIDS-defining diagnosis, and CD4+ counts of 0.200-0.499 x 10(9)/L (200-499/mm3) received 28 tablets each day of either a standardized oral preparation of 31 Chinese herbs or a cellulose placebo. Primary outcome measures were changes in life satisfaction, perceived health, and number and severity of symptoms. Other outcomes included adherence, and changes in weight, CD4+ count, depression, anxiety, physical and social function, and mental health. Two placebo- and no herb-treated subjects had mild adverse events (AE). Subjects on both arms reported taking 94% of prescribed tablets. No differences between treatment groups reached the p < 0.05 level. Life satisfaction improved in herb-treated [+0.86, 95% confidence interval (CI): +0.29, +1.43] but not in placebo-treated subjects (+0.20, 95% CI -0.35, + 0.75). Number of symptoms was reduced in subjects receiving herbs (-2.2, 95% CI -4.1, -0.3) but not in those receiving placebo (-0.3, 95% CI -3.2, +2.7). There were trends toward greater improvements among herb-treated subjects on all symptom subscales except dermatologic. Believing that one was receiving herbs was strongly associated with reporting that the treatment had helped (p < 0.005), but not with changes in life satisfaction or symptoms. There were improvements in life satisfaction and symptoms among subjects receiving the herbal therapy. Whether Chinese herbs are effective in the management of symptomatic HIV infection can be adequately addressed only by larger trials of longer duration.

Transthoracic intraaortic balloon pump: a simplified technique.

A technique of transthoracic intraaortic balloon pump insertion and a clinical experience with 14 patients is reported. The technique of transthoracic intraaortic balloon pump insertion can be done in a rapid and atraumatic fashion. A short prosthetic graft is used, and intraaortic balloon pump removal does not require resternotomy. The technique is a safe alternative in postcardiotomy failure patients with inadequate peripheral arterial access.

Microbiology of community-acquired bacterial pneumonia in persons with and at risk for human immunodeficiency virus type 1 infection. Implications for rational empiric antibiotic therapy.

BACKGROUND: Bacterial pneumonia is a very common cause of morbidity and mortality among persons with human immunodeficiency virus; however, the microbiologic characteristics (including antibiotic resistance) of bacterial pathogens causing community-acquired pneumonia in this population have not been well characterized or correlated with potentially predictive clinical presentation characteristics. METHODS: We conducted a retrospective cohort study of all adults known to have or to be at high risk for human immunodeficiency virus infection and hospitalized at San Francisco (Calif) General Hospital from May 1990 through April 1991, with a hospital discharge diagnosis of community-acquired bacterial pneumonia and for whom a medical records review confirmed that this diagnosis met a uniform case definition. RESULTS: Two hundred sixteen eligible patients had one or more hospital admissions meeting the case definition. One or more etiologic pathogens were definitively identified in 75% of cases, with Streptococcus pneumoniae, Haemophilus species, Staphylococcus aureus, and gram-negative bacilli most frequently identified. In patients who had a bacteriologic diagnosis made, 18.6%, 6.8%, and 4.3% had pneumonia caused by pathogens resistant to ampicillin sodium, cefuroxime sodium, or trimethoprim-sulfamethoxazole, respectively. One hundred percent of pathogens isolated were susceptible to ceftazidime. Anemia and use of antibacterial medication at the time of hospital admission were the only independent predictors of ampicillin and cefuroxime resistance. CONCLUSION: Nearly one fifth of human immunodeficiency virus-associated community-acquired bacterial pneumonias requiring hospitalization were caused by ampicillin-resistant pathogens, and presenting clinical characteristics did not consistently define a subset of patients at lower risk for resistance. In the absence of a diagnostic sputum Gram's stain and pending definitive microbiologic diagnosis, initial empiric therapy should be with a second- or third-generation cephalosporin or possibly trimethoprim-sulfamethoxazole.

Diagnostic lumbar puncture in HIV-infected patients: analysis of 138 cases.

PURPOSE: This study was designed to describe the cerebrospinal fluid (CSF) findings and neurologic diagnoses observed in human immunodeficiency virus (HIV)-infected adults undergoing diagnostic lumbar puncture (LP) and to correlate the results of LP with indications and CD4 counts. DESIGN: Retrospective cross-sectional chart review study. SETTING: University hospital clinic for patients with HIV infection. PATIENTS: All patients of the University of California, San Francisco (UCSF) AIDS Clinic who underwent LP between mid-1987 and mid-1990 for headache, fever, altered mental status, or a combination of these indications. Sixty-seven percent had an AIDS diagnosis at the time of LP; the median CD4 count was 0.091 x 10(9)/L. RESULTS: A total of 138 LPs was analyzed. Elevation of CSF protein and leukocytes occurred in 33% and 27% of specimens, respectively. Seventy-two new neurologic diagnoses were established in 67 patients, but only 30 diagnoses were the result of CSF analysis. Of these 30 diagnoses, 18 were of aseptic meningitis attributed to HIV. None of the 12 treatable diagnoses established by LP occurred in patients known to have a CD4 count of 0.200 x 10(9)/L or greater. Patients undergoing LP because of headache had a lower incidence of new diagnoses than those with altered mental status (35% versus 72%), but LP revealed a higher proportion of diagnoses in the group with headache. CONCLUSIONS: CSF abnormalities were common at all stages of disease. LP was diagnostic in 22% of cases, but fewer than half of the diagnoses were of treatable secondary complications. Patients with a CD4 count higher than 0.200 x 10(9) have a very low incidence of opportunistic complications. The relatively low yield of LP in patients with altered mental status suggests that other testing modalities should be used prior to LP.