Clinical factors that influence patients' desire for participation in decisions about illness.

BACKGROUND: Clinical practice often fails to optimize patient participation in decisions about serious illness. Prior studies are unclear about whether the type of decision and prior illness experience affect the patient's preferences for participation in decision making. Most studies of patient decision making have not addressed decisions about serious illness. OBJECTIVE: To determine whether the type of illness and nature of the decision predict the patient's preferences for involvement in making decisions. DESIGN: Study of randomly selected patients' responses to vignettes about cancer, acute myocardial infarction, and diabetes coupled with cross-sectional survey and chart review. SETTING: Outpatient Veterans Affairs medical clinic. PATIENTS: A total of 255 patients with a mean age of 63.2 years (95.2% male; 61.9% married). MAIN RESULTS: Patients wanted to share hypothesized major decisions with their physicians (mean score, 2.9; 1 = only physician, 5 = only patient) but wanted less involvement in hypothesized minor decisions (mean score, 2.5). Patients with recent severe heart disease (myocardial infarction, bypass surgery, angioplasty) wanted more involvement in decisions about acute myocardial infarction than did patients with stable angina or no heart disease; prior experience with diabetes did not affect decisions about diabetes. Factor analysis of the vignette items yielded 3 types of decisions that we consider to reflect major, minor, and patient behavior decisions. Mean scores were 2.9 for major decisions, 2.1 for minor decisions, and 2.7 for patient behavior decisions. CONCLUSIONS: Patients want to share in major decisions with their physicians but prefer to be less involved in minor decisions. For some illnesses, such as myocardial infarction, prior experience with the illness increases the patients' desire for participation in decision making. Arch Intern Med. 2000;160:2991-2996

Perceived barriers and biases in the medical education experience by gender and race.

This study examined barriers and biases in the medical education experience by surveying fourth-year medical students. There were 270 female and 288 male respondents; their racial background was: 21% Asian, 13% underrepresented minorities, and 66% white. Women reported that the careers they were encouraged to pursue were affected by their gender (44% versus 15%) and they were often mistaken for a nonphysician (92% versus 3%). More importantly, women reported that the lack of a mentor of either gender as a large barrier (27% versus 19%). Underrepresented minorities reported that their race caused them to feel that they had to be twice as good to be treated as an equal to other students (52% versus 6%). Underrepresented minorities identified the lack of a same-race mentor (23% versus 4%) and role model (40% versus 1%) as a large barrier. Underrepresented minorities also noted an overall lack of mentors as a large barrier (25% versus 19%). Women and underrepresented minorities from the class of 1996 reported having a medical school experience characterized by similar barriers to their professional development.