Patient perspectives on spirituality and the patient-physician relationship.

OBJECTIVE: To identify the preferences and concerns of seriously ill patients about discussing religious and spiritual beliefs with physicians. DESIGN: Three focus group discussions with patients who had experienced a recent life-threatening illness. Discussions were audiotaped, transcribed verbatim, and reviewed independently by two investigators to identify discrete comments for grouping into domains. A third investigator adjudicated differences in opinion. Comments were then independently reviewed for relevance and consistency by a health services researcher and a pastoral counselor. SETTING: Academic medical center. PARTICIPANTS: Referred sample of 22 patients hospitalized with a recent life-threatening illness. MEASUREMENTS AND MAIN RESULTS: Almost all of the 562 comments could be grouped into one of five broad domains: 1) religiosity/spirituality, 2) prayer, 3) patient-physician relationship, 4) religious/spiritual conversations, and 5) recommendations to physicians. God, prayer, and spiritual beliefs were often mentioned as sources of comfort, support, and healing. All participants stressed the importance of physician empathy. Willingness to participate in spiritual discussions with doctors was closely tied to the patient-physician relationship. Although divided on the proper context, patients agreed that physicians must have strong interpersonal skills for discussions to be fruitful. Physician-initiated conversation without a strong patient-physician relationship was viewed as inappropriate and as implying a poor prognosis. CONCLUSION: Religion and spirituality are a source of comfort for many patients. Although not necessarily expecting physicians to discuss spirituality, patients want physicians to ask about coping and support mechanisms. This exploratory study suggests that if patients then disclose the importance of spiritual beliefs in their lives, they would like physicians to respect these values.

A prospective comparative study of the compression hip screw and the gamma nail.

Achieving bony union and early weight bearing in peritrochanteric femur fractures poses a continuous challenge for the orthopedic surgeon. Current standards of surgical fixation for the myriad possible fracture patterns include the compression hip screw (CHS), the 90 degrees/95 degrees blade plate, and locked intramedullary nails. The gamma nail (GN) was designed as a "hybrid" of these devices, combining theoretical biomechanical advantages that should allow earlier postoperative weight bearing with surgical technique advantages that should decrease operative morbidity. Because these theoretical advantages were unproven in a clinical setting, we prospectively randomized 75 consecutive patients with peritrochanteric femur fractures into two groups to examine the fixation of these fractures with the GN as compared to the CHS. We found no significant differences in preoperative or intraoperative parameters. Postoperatively, the subtrochanteric fracture group treated with the GN achieved earlier weightbearing status, although this was not statistically significant. 72 patients were available for follow-up at a minimum of 6 months. All fractures had clinically and radiographically healed, and 94% of the patients continued to be ambulatory. Major complications included missed distal locking screws (one patient), cutting out of the lag screw superiorly in the femoral head (two patients), and a femur fracture at the distal end of the GN (one patient). In our series, the GN produced clinical results commensurate with current standards of fixation for peritrochanteric femur fractures. Although the GN allowed earlier independent weightbearing status in patients with subtrochanteric fractures, the procedure was technically more demanding and had a significant learning curve.