Hospitalised patients' views on doctors and white coats.

OBJECTIVES: To determine hospitalised patients' feelings, perceptions and attitudes towards doctors and how these are affected by whether or not doctors wear a white coat. DESIGN: Cross-sectional questionnaire survey. SETTING: The medical and surgical wards of two Sydney teaching hospitals, on one day in January 1999. PATIENTS: 154 of 200 consecutive patients (77%). MAIN OUTCOME MEASURES: The effects of white-coat-wearing on patients' feelings and ability to communicate and on their perceptions of the doctor; why patients think doctors wear white coats and their preferences for the wearing of white coats and doctors' attire in general; and patients' rating of the importance of these effects and preferences. RESULTS: Patients reported that white-coat-wearing improved all aspects of the patient-doctor interaction, and that when doctors wore white coats they seemed more hygienic, professional, authoritative and scientific. The more important that patients considered an aspect, the greater the positive effect associated with wearing a white coat. From a list of doctors' reasons for wearing white coats, patients thought that doctors wore white coats because it made them seem more professional, hygienic, authoritative, scientific, competent, knowledgeable and approachable. 36% of the patients preferred doctors to wear white coats, 19% preferred them not to wear white coats and 45% did not mind. CONCLUSIONS: Patients reported feeling more confident and better able to communicate with doctors who wore white coats. The recognition, symbolism and formality afforded by a white coat may enhance communication and facilitate the doctor-patient relationship.

Trial-to-trial fluctuations in H-reflexes and motor evoked potentials in human wrist flexor.

The H-reflexes and the motor potentials (MEPs) evoked by electromagnetic brain stimulation in the human wrist flexor were recorded over many trials. The responses from each stimulus at two steady levels of muscle activation were sorted into three groups, based on their amplitudes. The electromyogram (EMG) in each of these groups was rectified and averaged. The level of pre-response muscle activity was found to correlate with the amplitude of both the averaged H-reflexes and the averaged MEPs. This suggests that much of the amplitude fluctuations of both H-reflexes and MEPs can be attributed to moment-to-moment changes in the level of activity of the motoneurone pool. Overall, however, the amplitude of MEPs increased more rapidly than the amplitude of H-reflexes as the pre-stimulus EMG activity increased. This is probably because, while the amplitude of H-reflexes depends primarily on the level of motoneurone pool excitability, the amplitude of an MEP depends not only on this, but also on the excitability of the motor cortex, and the former is to some extent also dependent on the latter.

Motor cortical control of human masticatory muscles.

The corticotrigeminal projections to masseter and anterior digastric motoneuron pools that are activated by TMS are bilateral, but not symmetrical. This conclusion is supported by whole-muscle data showing larger MEPs in the contralateral muscle with unilateral focal TMS, as well as evidence that TMS stimulation of one hemisphere may produce excitation in a masseter or digastric single motor unit while stimulation of the opposite hemisphere produced inhibition of the same motor unit. The asymmetry is particularly marked for masseter, in which the low-threshold motor units were most commonly excited with contralateral TMS and inhibited with ipsilateral TMS. Spike-triggered averaging of digastric motor unit activity revealed cross-talk in surface EMG recordings from digastric muscles, and no evidence that muscle fibres in both digastric muscles were innervated by a common motor axon. Narrow excitatory peaks in the PSTH of motor unit discharge elicited by TMS in masseter (either hemisphere) and digastric motor units (ipsilateral hemisphere) suggest a direct corticomotoneuronal projection. The contralateral projection to digastric motoneurons may include additional oligosynaptic connections, as judged by the broader peaks in the PSTH with contralateral TMS. The organisation of bilateral corticotrigeminal inputs revealed with TMS suggests that: (a) the contralateral hemisphere provides relatively more of the excitatory input delivered via the fast corticotrigeminal pathway for both masseter and digastric motoneuron pools, and (b) corticotrigeminal projections from either hemisphere are capable of contributing to the voluntary command mediating activation of masseter, and (to a lesser extent) anterior digastric muscles on one side, that is independent of the homologous muscles on the other side.

Bilateral cortical control of the human anterior digastric muscles.

Transcranial magnetic stimulation (TCMS) was used to determine the organization of cortical motor projections to the anterior digastric muscles in 12 normal human subjects. Two distinct types of potentials were evoked in anterior digastric with a figure-of-eight coil. A short-latency (3 ms) response appeared bilaterally on the surface electromyogram (EMG), but only ipsilaterally on intramuscular recordings: this was the result of direct stimulation of the ipsilateral trigeminal motor root. Motor evoked potentials (MEPs) were elicited in the anterior digastric muscles at variable onset latencies of around 10 ms by stimulation of scalp areas antero-lateral to the area for the first dorsal interosseous muscle of the hand. These were evoked bilaterally in relaxed anterior digastric muscles in six of the seven subjects. In the other subject, the responses in the relaxed muscle were exclusively ipsilateral. However, when the anterior digastric muscles were contracted, the responses were bilateral in all subjects. TCMS and spike-triggered averaging revealed that the bilateral responses were not due to the branching of axons from individual digastric motoneurones to muscles on each side. Because the digastric motor nucleus may contain separate populations of ipsi- and contralateral projecting motoneurones, it was necessary to study single motor-unit responses to TCMS to demonstrate a bilateral corticobulbar projection. The responses of 17 single motor units in the anterior digastric muscle to TCMS were recorded. All were activated by contralateral stimulation. Approximately 80% were also activated by ipsilateral TCMS, although one well-characterised motor unit was inhibited by ipsilateral TCMS. When bilateral activation was present, the ipsilateral responses were more secure than the contralateral responses, which may indicate an additional interneurone in the pathway to the contralateral motoneurone. The major conclusions from this study are that (1) the cortical representation of the anterior digastric muscle is antero-lateral to hand muscles; (2) the cortical projection to the anterior digastric muscles is bilateral; (3) the corticobulbar projection is stronger contralaterally than ipsilaterally but may involve at least one additional synapse; and (4) anterior digastric motoneurones do not branch to innervate the muscles bilaterally.