Talking about AIDS

Despite increased public and professional awareness, patients and physicians tend to avoid discussions about HIV. Empiric studies of patient-physician communication point to specific common communication breakdowns. These include lack of a good opening line, inappropriate context, awkward moments, vague language, and a physician-centered rather than a patient-centered interview style. In effective HIV-related discussions, clinicians elicit the patient's beliefs and concerns first, are organized, use empathy, provide a rationale for the discussion, persist through awkward moments, and clarify vague language. In addition to information about sexual behaviors and the number, gender, and HIV status of partners, clinicians should ask about the context and antecedents to risk behaviors, praise prior attempts to reduce risk, and assess the patient's motivation to change. Although studies indicate that experienced practitioners often do not have these skills, they can be learned.

Toward creating physician-healers: fostering medical students' self-awareness, personal growth, and well-being

To restore the "humanism" in medical care, medical education needs to espouse the goal of creating physician-healers. Critical, and often neglected, factors in healing are the personal development and well-being of the healer. Unexamined attitudes and biases and personal stress can interfere with patient care. Personal awareness and well-being can contribute to physicians' using their emotional reactions to patients for their patients' benefit. The authors suggest goals and objectives for medical education that can promote trainees' self-awareness, personal growth, and well-being, and comment on how medical educators might achieve and evaluate these goals and objectives.

Somatization reconsidered: incorporating the patient's experience of illness

The large and heterogeneous group of patients with "unexplained somatic symptoms," with or without coexisting psychiatric, "functional," or "organic" illnesses, provides continuing difficulty for clinicians. The construct of somatization artificially separates bodily and psychological symptoms that patients experience as a unified whole. Concurrent chronic illnesses make it difficult to exclude "general medical conditions." The diagnosis requires that the patient seek medical care. Conflict between patients' experiences of illness and physicians' diagnostic categories, and fear of blaming the patient, complicate naming and characterizing the illness. We recommend an approach to clinical care that involves exploring the patient's life context, finding mutually meaningful language to arrive at a name for the illness, normalizing the patient's bodily experience of distress, using a chronic disease model that attends to functioning, and addressing the physician's need for certainty and efficacy. Health systems can help coordinate care and avoid iatrogenic harm by appropriately controlling access to medical services.

Respiratory factors in the uptake and excretion of anesthetics. 1965

We have considered some of the ways in which respiration can affect the gas exchange process. The simplest relationships are purely physical and relate to the speed with which the lung and tissues can be filled or emptied. More complex relationships involve a consideration of the interplay between blood and gas in the lung and the effects of gas exchange on respiratory volumes themselves. Finally, some examples of the importance of physiologic alteration produced by, and producing respiratory shifts during, gas uptake processes were presented briefly. The detailed interpretation of gas exchange phenomena demands more quantitative information of this sort, concerning not only the respiratory but the circulatory and tissue level variations affecting uptake during anesthesia. Nevertheless, understanding of the principles and application of such data as are available can go far toward removing the handicaps of empirical practice from the day-to-day administration of anesthetic agents to human beings.

Soliciting the patient's agenda: have we improved?

CONTEXT

Previous research indicates physicians frequently choose a patient problem to explore before determining the patient's full spectrum of concerns.

OBJECTIVE

To examine the extent to which experienced family physicians in various practice settings elicit the agenda of concerns patients bring to the office.

DESIGN

A cross-sectional survey using linguistic analysis of a convenience sample of 264 patient-physician interviews.

SETTING AND PARTICIPANTS

Primary care offices of 29 board-certified family physicians practicing in rural Washington (n = 1; 3%), semirural Colorado (n = 20; 69%), and urban settings in the United States and Canada (n = 8; 27%). Nine participants had fellowship training in communication skills and family counseling.

MAIN OUTCOME MEASURES

Patient-physician verbal interactions, including physician solicitations of patient concerns, rate of completion of patient responses, length of time for patient responses, and frequency of late-arising patient concerns.

RESULTS

Physicians solicited patient concerns in 199 interviews (75.4%). Patients' initial statements of concerns were completed in 74 interviews (28.0%). Physicians redirected the patient's opening statement after a mean of 23.1 seconds. Patients allowed to complete their statement of concerns used only 6 seconds more on average than those who were redirected before completion of concerns. Late-arising concerns were more common when physicians did not solicit patient concerns during the interview (34.9% vs 14.9%). Fellowship-trained physicians were more likely to solicit patient concerns and allow patients to complete their initial statement of concerns (44% vs 22%).

CONCLUSIONS

Physicians often redirect patients' initial descriptions of their concerns. Once redirected, the descriptions are rarely completed. Consequences of incomplete initial descriptions include late-arising concerns and missed opportunities to gather potentially important patient data. Soliciting the patient's agenda takes little time and can improve interview efficiency and yield increased data.

Awkward moments in patient-physician communication about HIV risk

BACKGROUND

Physicians frequently encounter patients who are at risk for HIV infection, but they often evaluate risk behaviors ineffectively.

OBJECTIVE

To describe the barriers to and facilitators of comprehensive HIV risk evaluation in primary care office visits.

DESIGN

Qualitative thematic and sequential analysis of videotaped patient-physician discussions about HIV risk. Tapes were reviewed independently by physician and patient and were coded by the research team.

SETTING

Physicians' offices.

PARTICIPANTS

Convenience sample of 17 family physicians and general internists. Twenty-six consenting patients 18 to 45 years of age who indicated concern about or risks for HIV infection on a 10-item questionnaire administered before the physician visit were included.

MEASUREMENTS

A thematic coding scheme and a five-level description of the depth of HIV-related discussion.

RESULTS

In 73% of the encounters, physicians did not elicit enough information to characterize patients' HIV risk status. The outcome of HIV-related discussions was substantially influenced by the manner in which the physician introduced the topic, handled awkward moments, and dealt with problematic language and the extent to which the physician sought the patient's perspective. Feelings of ineffectiveness and strong emotions interfered with some physicians' ability to assess HIV risk. Physicians easily recognized problematic communication during reviews of their own videotapes.

CONCLUSIONS

Comprehensive HIV risk discussions included providing a rationale for discussion, effectively negotiating awkward moments, repairing problematic language, persevering with the topic, eliciting the patient's perspective, responding to fears and expectations, and being empathic. Educational programs should use videotape review and should concentrate on physicians' personal reactions to discussing emotionally charged topics.

How students learn from community-based preceptors

OBJECTIVE

To explore how students learn in community-based family physicians' offices from the student's point of view.

METHOD

Each student completing a community-based family medicine clerkship wrote a "critical incident" narrative about an event that was particularly educational. A coding system was developed by a multidisciplinary research team and thematic analysis was conducted.

RESULTS

Critical education experiences were brief, problem-focused, had definitive outcomes, were often collaborative, and led to self-reflection. The most commonly identified mode of learning was "active observation." In most of these situations, the student had significant clinical responsibility, but some involved observation of complex tasks beyond the expectations of a medical student. Most (77%) identified their learning needs after having observed a preceptor, rather than prospectively. Collaboration, coaching, advocacy, and exploring affect were means whereby preceptors and students created a learning environment that students felt was safe, allowed them to recognize their own learning needs, and helped them adopt new behaviors.

CONCLUSIONS

These findings broaden the definition of active learning to include active observation and support learner-centered and relational models of learning. Increasing preceptors' awareness of these modes of student learning will enhance the quality of education in ambulatory settings.

Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient

Physicians' personal characteristics, their past experiences, values, attitudes, and biases can have important effects on communication with patients; being aware of these characteristics can enhance communication. Because medical training and continuing education programs rarely undertake an organized approach to promoting personal awareness, we propose a "curriculum" of 4 core topics for reflection and discussion. The topics are physicians' beliefs and attitudes, physicians' feelings and emotional responses in patient care, challenging clinical situations, and physician self-care. We present examples of organized activities that can promote physician personal awareness such as support groups, Balint groups, and discussions of meaningful experiences in medicine. Experience with these activities suggests that through enhancing personal awareness physicians can improve their clinical care and increase satisfaction with work, relationships, and themselves.

Communication between primary care physicians and consultants

Optimal communication between primary care physicians and consultants includes transfer of relevant clinical information, including the patient's perspectives and values, and provides a means of collaboration to provide meaningful and health-promoting interventions. Communication difficulties arise because of lack of time, lack of clarity about the reason for referral, patient self-referral, and unclear follow-up plans. Also, primary care physicians and consultants may have different core values and may have little day-to-day contact with each other. Poor communication leads to disruptions in continuity of care, delayed diagnoses, unnecessary testing, and iatrogenic complications. Changes in the health care system offer the opportunity for improved collaboration between physicians by creating smaller administrative units within large health care systems that facilitate contact between primary care physicians and consultants; incorporation of discussions of uncertainty, patient preferences, and values into referral letters; adoption of a friendlier consultant letter format; and the improvement of the transfer of clinical data.

Perspectives on patient-doctor communication

Until recently, the content, structure, and function of communication between doctors and patients has received little attention and has been excluded from the realm of scientific inquiry; as a result, most clinicians have had little formal training in communication skills. In this paper leaders in doctor-patient communication present four approaches that are currently used as the basis for clinical training and research, summarize the progress made in forming a consensus, and outline the implications of these perceptions for practicing physicians.

Understanding fear of contagion among physicians who care for HIV patients

BACKGROUND

Fear of contagion has been identified as a potential deterrent for primary care physicians who would otherwise care for HIV patients. This study examines physicians' fears of occupational HIV transmission and the ways that they cope with those fears.

METHODS

Thirty community-based primary care physicians who were caring for HIV patients were interviewed about their experiences with HIV patients and the meanings they ascribe to those experiences. Qualitative content and narrative analysis were used.

RESULTS

Fear of contagion was common despite the relatively low reported self-assessment of risk by primary care physicians. Most physicians considered their level of risk acceptable, but for some it seemed to take a high emotional toll. Some physicians identified their fear as "irrational." Physicians reported tension between fear of contagion and ethical responsibility to care for HIV patients. Some physicians were overattentive to infection control measures, whereas others used universal precautions inconsistently. Physicians continued to care for HIV patients despite their fears. Some physicians' family members needed information and reassurance about transmission of HIV.

CONCLUSIONS

Some physicians who care for HIV patients are poorly equipped to deal with their own fears. There is a need to examine in greater depth the relationship between fear of contagion and willingness to provide care, and to examine other factors that may be contributing to the expression of these fears.

Primary care of patients with human immunodeficiency virus infection. The physician's perspective

OBJECTIVE

To examine physicians' perceptions, motivations, and influences on their willingness to care for patients with human immunodeficiency virus (HIV).

DESIGN

Interviews with 30 physicians. Qualitative content and narrative analyses were performed.

SETTINGS

Community-based primary care practices in six moderate-sized cities in the northeastern United States with at least a moderate incidence or prevalence of reported acquired immunodeficiency syndrome cases.

PARTICIPANTS

Thirty community-based primary care physicians who had cared for at least two patients with HIV during the previous 2 years.

MAIN OUTCOME MEASURE

Qualitative study designed to provide rich descriptive data.

RESULTS

Care of patients with HIV was regarded as part of the scope of primary care, and was perceived to be similar to the care of patients with other chronic illnesses. Many physicians were motivated by personal rewards in taking care of patients, intellectual challenge, and desire to serve the underserved. Most believed that practicing physicians have an ethical obligation to care for all patients, regardless of diagnosis. No one "type" of physician could be identified who provides care to patients with HIV.

CONCLUSIONS

Primary care physicians can apply their skills in the management of other chronic diseases to the care of patients with HIV. Practicing physicians can find caring for patients with HIV rewarding, stimulating, and enjoyable. Educational programs for physicians need to emphasize psychosocial aspects of HIV care. In addition, physicians need opportunities to recognize and deal effectively with their own emotional responses to the care of patients with HIV.

Photodegradation of sodium nitroprusside: biologic activity and cyanide release

Because the belief that cyanide is released from nitroprusside in vivo recently was challenged, the authors performed a series of experiments that examined the conditions under which nitroprusside is degraded. These experiments include an examination of the release of cyanide and nitric oxide from nitroprusside in vitro, the release of cyanide in vivo, and a comparison of the biologic activity of intact and degraded nitroprusside. Nitroprusside in aqueous solution degraded when exposed to white or blue light but not to red light. While light at 20 microW X cm-2 produced 40% apparent photodegradation after 6 h exposure, while white light at 220 microW X cm-2 produced 100% apparent photodegradation after 2 h exposure. At 10% apparent photodegradation, 10% of the nitrosyl ligand was recovered as free nitric oxide, and 0.4% of the cyanide ligand was recovered as free cyanide. Following a 2-h infusion of light-protected nitroprusside in seven patients, cyanide concentrations ranged from 1.4 to 45.5 microM and 0.09 to 3.2 microM in blood and plasma, respectively. These values were not changed by exposing the samples to white light (220 microW X cm-2) for 4 h. Intact and photodegraded nitroprusside produced identical hypotensive responses in rats as would be expected, since the nitrosyl ligand was detected in solution following degradation, and it mediates this action. Cyanide was released from nitroprusside, both on its exposure to light in vitro and also in vivo. The latter was not an artifact of the assay for cyanide. Nitroprusside releases cyanide in vivo, and cyanide toxicity is a true complication of its use.

Captopril reduces the dose requirement for sodium nitroprusside induced hypotension

The authors studied 12 patients who required deliberate hypotension for spinal fusion operations in order to investigate the efficacy of captopril for reducing dose requirement for sodium nitroprusside (SNP). Six patients, selected at random, were pretreated with captopril, 3 mg/kg po, and the remaining six patients served as controls. All patients received a similar anesthetic technique, consisting of thiopental 3 mg/kg, pancuronium 0.1 mg/kg, morphine 0.5 mg/kg, plus nitrous oxide 70% in oxygen. SNP was used to maintain mean arterial pressure (MAP) at 50-55 mmHg during deliberate hypotension lasting 140 +/- 13 minutes (mean +/- SE). Patients who received captopril required less SNP than untreated patients both early during hypotension (1.4 +/- 0.5 micrograms X kg-1 X min-1 vs. 4.8 +/- 0.8 micrograms X kg-1 X min-1, P less than 0.05), as well as late during hypotension (2.2 +/- 0.2 micrograms X kg-1 X min-1 vs. 5.6 +/- 0.6 micrograms X kg-1 X min-1, P less than 0.05). Whole blood cyanide was significantly lower in the patients pretreated with captopril than the untreated controls both early in the hypotensive period (2.7 +/- 0.6 mumol/l vs. 13 +/- 4 mumol/l, P less than 0.05) and also late in the hypotensive period (3.7 +/- 0.8 mumol/l vs. 30 +/- 10 mumol/l, P less than 0.05). MAP was reduced by captopril pretreatment both following induction of anesthesia (64 +/- 4 mmHg captopril vs. 80 +/- 4 mmHg control, P less than 0.05) and during surgery before deliberate hypotension (86 +/- 5 mmHg captopril vs. 100 +/- 4 control, P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Resonance Raman studies on protocatechuate 3,4-dioxygenase-inhibitor complexes

Resonance Raman spectra of a number of protocatechuate 3,4-dioxygenase-inhibitor complexes were studied by use of the available lines of an argon and a krypton laser. Three types of inhibitors were investigated-hydroxybenzoates, dicarboxylates, and 4-nitrocatechol. The hydroxybenzoate study shows that the hydroxy group in 3-hydroxybenzoate does not coordinate to the active site iron, in agreement with earlier suggestions, and confirms the coordination of the hydroxy group in the isomeric 4-hydroxybenzoate. The dicarboxylate study demonstrates that both glutarate and terephthalate perturb the active-site environment, shifting the charge-transfer interaction to lower energy. The pH dependence of terephthalate binding as well as the spectral similarities of the dicarboxylate complexes to the ESO2 intermediate provides further evidence for the suggestion that this intermediate is a tightly bound enzyme-product complex. The 4-nitrocatechol study indicates that, unlike the substrate catechols, 4-nitrocatechol does not bind to the iron; a binding configuration wherein the acidic phenolate group interacts with the carboxylate binding site has been suggested by others. Finally the spectra of the 4-hydroxybenzoate and terephthalate complexes demonstrate the presence of two tyrosines coordinated to the active-site iron as suggested by others; these tyrosines have different vCO's and excitation profiles.