[A cross-cultural study of physician treatment decisions in relation to demented nursing home patients who develop pneumonia]

This qualitative interview study in The Netherlands and North Carolina (US) found that physician treatment decisions are influenced by contextual differences in physician training and healthcare delivery in the US and The Netherlands. Dutch physicians treating nursing home residents with dementia and pneumonia assumed active, primary responsibility for treatment decisions while US physicians were more passive and deferential to family preferences, even in cases where they considered the families' wishes inappropriate. Dutch physicians knew their patients well and made treatment decisions based on what they perceived was in the best interest of the patient while US physicians reported limited knowledge of their nursing home patients due to a lack of contact time. Efforts to improve care for patients with poor quality of life who lack decision-making capacity must consider the context of societal values, physician training, and the processes by which physicians negotiate patient and family preferences.

Spirituality and well-being: an exploratory study of the patient perspective

Spirituality has become a construct of interest in American health care: however, there remains a limited understanding of how patients themselves describe spirituality and view its impact on their health and well-being. The purpose of this study was to identify and describe elements of patient-reported, health-related spirituality. A qualitative study utilized focus group interviews of 17 women with type 2 diabetes mellitus and 18 women with no self-identified illness. Purposeful sampling of participants who had prior experiences in healthcare settings, with or without a chronic illness, guided the sampling strategy. Editing analysis of the interview transcripts were coded into conceptual categories. Participant narratives were grouped into eight general categories: (1) change in functional status, (2) core beliefs, (3) medical/disease state information gathering and processing, (4) interpretation and understanding, (5) life scheme, (6) positive intentionality, (7) agency, and (8) subjective well-being. A change in functional status was the catalyst for two process-oriented categories; medical/disease state information gathering and processing, and the higher-order interpretation and understanding, or meaning making of life events. Core beliefs were sources that grounded and maintained an interpretative structure through which participants viewed their life events and positively framed their experiences. Life scheme described a heuristic framework through which all life events were viewed. Positive intentionality was participant belief in the capacity to execute a specific action that was required for a desired outcome. Participants tied the attitudes and practices of positive intentionality with agency, or the use or exertion of power through belief, practice, or community. Participants outlined both a positive affective and cognitive component of subjective well-being. Patients describe several interrelated elements and a process of events in their depiction of spirituality in healthcare settings. Patient-reported spirituality is predominantly a cognitive construct incorporating the domains of life scheme and positive intentionality.

Kimura's disease presenting as subcutaneous facial plaque in an African American

Kimura's disease is a benign, uncommon, chronic inflammatory condition that usually presents with painless subcutaneous nodules or plaques in the head and neck region. Although the disease is predominantly found in Asian populations, there are occasional cases reported among Caucasians and rare occurrences in African populations. The etiology and pathogenesis of the disease are unknown and the clinical presentation can mimic several benign and malignant disease states. The accurate diagnosis of Kimura's disease is based on clinical and histopathological findings. There is no evidence of malignant transformation and occasional spontaneous resolution occurs. Various treatment modalities have been suggested in the management of this condition. Oral corticosteroids have been the mainstay of therapy, even though steroid withdrawal can result in lesion recurrence.

The natural history of cervical cryosurgical healing. The minimal effect of debridement of the cervical eschar [see comment]

BACKGROUND

Cryosurgery is a favored treatment method for cervical intraepithelial neoplasia (CIN) among family physicians, in part because it is inexpensive and requires the least technical training and skill. Although cervical cryosurgery has been used for more than 30 years, the natural history of the postprocedure process has never been described. The primary purpose of our study was to describe the natural history of the healing process after cervical cryosurgery. A secondary purpose was to determine the effect of mechanical debridement of the cervical eschar on the symptoms of healing.

METHODS

We conducted a prospective multicentered trial in which women who had a histologic ally documented CIN lesion underwent cervical cryosurgery. Forty-six women were randomized to undergo eschar debridement at 48 hours after cryosurgey, and 38 women received standard care. All women were followed up and given preweighed sanitary pads for hydrorrhea (watery discharge) collection and a diary to record the severity and number of days of odor, pain, cramping, and hydrorrhea that were experienced.

RESULTS

The average total amount of hydrorrhea or discharge was 288 g, which required using an average of 41 sanitary pads during a period of 12.4 days. The duration of odor was 8.9 days, and the pain and cramping experienced after cryosurgery lasted 4.7 days. Women who were obese had greater hydrorrhea and pad usage than nonobese women. Debridement of the cervical eschar did not significantly change the signs and symptoms of healing after cryosurgery.

CONCLUSIONS

There are significant symptoms patients experience after cryosurgery that are not ameliorated by debridement. The expectations of the cryosurgical healing process should be disclosed to women before the procedure.

Healing experiences after cervical cryosurgery

BACKGROUND

Treatment for cervical intraepithelial neoplasia with cryosurgery is uncomfortable for many women. The subsequent healing process is also thought to bring discomfort. The purpose of our study was to describe women's experiences after cryosurgery, and how obesity, age, and gravidity affected, the healing process.

METHODS

We developed a survey from focus group results to measure the unpleasantness of hydrorrhea (watery discharge) from cryosurgery, the pad protection required, and the odor associated with the hydrorrhea. The cryosurgical experiences were compared with normal menses for the use and frequency of pad protection, medications used, and any activity restrictions.

RESULTS

Cryosurgical experiences were unpleasant for 78.3% of the women because of the pain and cramping of the procedure and the resulting hydrorrhea, odor, and necessity of wearing pads for protection. These experiences after cryosurgery caused 38.6% to restrict their activities and 67.1% to take medications, a significantly greater proportion than the 16.9% whose activities were restricted normal menses and the 26.8% who took medications for normal menses (P=-.004, P <.001, respectively). In addition to these experiences, obese, multigravid, and older women were more bothered by the duration of wearing pads than their counterparts (P=.0246, =.0061, and P=.0159, respectively).

CONCLUSIONS

Our study showed that the cryosurgical healing process was not pleasant, and was least tolerable for obese, multigravid, and older women. As many as 50% of women undergoing cryosurgery will perceive the hydrorrhea, its odor, and the wearing of pads to be worse than normal menses, especially if their menses are usually light.

Spiritual and religious beliefs and practices of family physicians: a national survey

BACKGROUND

The current movement in American medicine toward patient-centered or relationship-centered care highlights the importance of assessing physician core beliefs and personal philosophies. Religious and spiritual beliefs are often entwined within this domain. The purpose of this study was to identify the personal religious and spiritual beliefs and practices of family physicians and to test a valid and reliable measure of religiosity that would be useful in physician populations.

METHODS

An anonymous survey was mailed to a random sample of active members of the American Academy of Family Physicians who had the self-designated professional activity of direct patient care. Physicians reported their religious and spiritual beliefs and practices, including frequency of religious service attendance and private prayer or spiritual practice, and self-reported intrinsic or subjective religiosity.

RESULTS

Seventy-four percent of the surveyed physicians reported at least weekly or monthly service attendance, and 79% reported a strong religious or spiritual orientation. A small percentage (4.5%) of physicians stated they do not believe in God. A 3-dimensional religiosity scale that assessed organized religious activity, nonorganized religious activity, and intrinsic religiosity was determined to be a valid and reliable measure (alpha = .87) of physician religious and spiritual beliefs and practices.

CONCLUSIONS

Family physicians report religious and spiritual beliefs and practices at rates that are comparable with the general population.

Prevalence and patterns of physician referral to clergy and pastoral care providers

BACKGROUND

There is a heightened interest in spiritual and religious interventions in clinical settings, an area marked by unease and lack of training by physicians. A potential resource for generalists is specialty consultation and referral services, although little is known about the prevalence and patterns of involvement of clergy or pastoral professionals in patient care.

OBJECTIVES

To identify the prevalence and patterns of physician-directed patient referral to or recommended consultation with clergy or pastoral care providers and to describe attitudinal and demographic variables that can predict referring and nonreferring physicians.

DESIGN

A mailed anonymous survey.

SETTING

Family physicians in the United States.

PARTICIPANTS

Active members of the American Academy of Family Physicians whose self-designated professional activity is direct patient care. Of the 756 randomly selected physicians for participation in the study, 438 (57.9%) responded.

MAIN OUTCOME MEASURES

Physician reporting on their attitudes and referral behaviors, including referral frequency, and conditions or reasons for referral or nonreferral to clergy and pastoral care providers.

RESULTS

More than 80% of the physicians reported that they refer or recommend their patients to clergy and pastoral care providers; more than 30% stated that they refer more than 10 times a year. Most physicians (75.5%) chose conditions associated with end-of-life care (ie, bereavement, terminal illness) as reasons for referral. Marital and family counseling were cited by 72.8% of physicians; however, other psychosocial issues, such as depression and mood disorders (38.7%) and substance abuse (19.0%), were less prevalent. Physicians who reported a greater degree of religiosity had a small increased tendency to refer (r = 0.39, P<.05) to these providers. In addition, physicians who were in practice for more than 15 years were more likely to refer to clergy (P<.01).

CONCLUSIONS

Most family physicians accept clergy and pastoral professionals in the care of their patients. In medical settings, the providers of religious and spiritual interventions have a larger and more expanded role than previously reported.

Fever without source in infants and young children

Febrile infants and young children pose a challenge to primary care physicians because the clinical appearance of children who present with fever without source that is related to a viral illness may be similar to the appearance of those with occult bacteremia. The evaluation of the febrile infant and child comprises a comprehensive history, a thorough physical examination and judicious use of laboratory studies. The information derived from this evaluation will help clinicians with the two key management decisions that face physicians caring for this vulnerable population: the initiation and use of antimicrobial therapy, and inpatient versus outpatient management. Although no optimal diagnostic and therapeutic schema exists, physicians should take a structured and rational approach to these patients, depending on their own clinical experience and interpretation of the literature on this topic.

Patient attitudes regarding physician inquiry into spiritual and religious issues

BACKGROUND

Most physicians do not address spiritual and religious issues with patients, although there are data documenting the relationship between religious variables and disease, health, and well-being. The purpose of this study was twofold: to examine patient attitudes regarding physician-directed inquiry about issues related to spiritual matters and faith; and to identify screening variables that would identify patients who would be receptive to such a discussion.

METHODS

A Spiritual and Religious Inquiry (SRI) questionnaire was administered to patients presenting for care in a family practice center.

RESULTS

Patients' frequency of religious service attendance (at least monthly) predicted their acceptance of physician inquiry into their religion and personal faith (P < .01) and acceptance of physician referral to pastoral professionals for spiritual problems (P < .01).

CONCLUSIONS

This study supports the use of frequency of religious service attendance as a screening variable for patients receptive to physician-directed inquiry into religious and spiritual issues. It also confirms that patients are accepting of physicians' referring patients to pastoral professionals (ie, clergy) for spiritual problems.