Women battering in primary care practice.
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BACKGROUND: The organization of health care system to emphasize managed care has placed the primary care provider in an ideal position to assess the impact of intimate partner violence (IPV) on the health of women. Primary care practice provides a setting in which women can develop an ongoing relationship with their health care provider in which they feel safe to discuss IPV and possible options to improve their lives. Women's health and safety could be dramatically improved if primary care providers were prepared to assess, intervene and appropriately refer women who are in violent relationships. OBJECTIVES: The purpose of this article is to describe the prevalence of intimate partner violence in primary care populations and review the known physical, mental health and pregnancy consequences of abuse as well as discuss the implications of intimate partner violence on primary care practice. (+info)
Strategic physician communication and oncology clinical trials.
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PURPOSE: Clinical trials are the primary means for determining new, effective treatments for cancer patients, yet the number of patients that accrue is relatively limited. The purpose of this study was to explore the relationship between physician behavior and patient accrual to a clinical trial by videotaping the interaction. PATIENTS AND METHODS: Forty-eight patient-physician interactions involving 12 different oncologists were videotaped in several clinics at the H. Lee Moffitt Cancer Center and Research Institute (Tampa, FL). The purpose of each interaction was to present the possibility of a clinical trial to the patient. A coding system, the Moffitt Accrual Analysis System, was developed by the authors to code behaviors that represented both the legal-informational and social influence models of communication behavior. Thirty-two patients agreed to participate in the clinical trial. RESULTS: Videotaping was found to be a viable, valid, and reliable method for studying the interaction. Physicians who were observed to use both models of influence were found to enroll more patients. Thus, patients were more likely to accrue to the trial when their physician verbally presented items normally included in an informed consent document and when they behaved in a reflective, patient-centered, supportive, and responsive manner. Discussion of benefits, side effects, patient concerns and resources to manage the concerns were all associated with accrual. CONCLUSION: This research has implications for modifying physician behavior and, thus, increasing the numbers of patients accruing to oncology clinical trials. (+info)
Interpersonal processes of care in diverse populations.
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Persons of lower socioeconomic status and members of racial and ethnic minority groups experience poorer health and increased health risk factors. A framework of interpersonal processes of care specifies distinct components and incorporates the perspective of diverse racial and ethnic or socioeconomic groups. Its dimensions, each with several domains, are communication (general clarity, elicitation of and responsiveness to patient concerns, explanations, empowerment), decision making (responsiveness to patient preferences, consideration of ability and desire to comply), and interpersonal style (friendliness, respectfulness, discrimination, cultural sensitivity, support). All the domains, except cultural sensitivity, were validated through a survey of 603 ethnically diverse, low-income adults. Confirmation of the framework's usefulness should enable researchers to explore how interpersonal processes might account for observed ethnic and social class differences in health care and health. (+info)
Diabetes in urban African-Americans. XV. Identification of barriers to provider adherence to management protocols.
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OBJECTIVE: To determine whether health care providers appropriately identify patients with poor glycemic control and to investigate reasons why providers may fail to intensify therapy in these patients. RESEARCH DESIGN AND METHODS: Our management protocol calls for providers to advance diabetes therapy in patients with fasting plasma glucose levels > 7.8 mmol/l or random plasma glucose levels > 10.0 mmol/l. During a 3-month period, providers completed a questionnaire at the end of individual patient visits by asking whether the patient was well controlled and whether therapy was advanced. If therapy was not advanced in patients perceived to have poor control, providers were asked to provide a justification. RESULTS: Providers appropriately identified 88% of well-controlled patients and 94% of patients with poor glycemic control. Out of 1,144 patient visits, control was reported to be good in 508 and poor in 636. In these 636 visits, therapy was advanced in 490 but not in 146 visits. The dominant reasons for failure to intensify therapy were the perception by the provider that control was improving (34%) or the belief that the patient was not compliant with diet or medications (25%). Less common reasons included acute illness, patient refusal, and recurrent hypoglycemia. Based on fasting glucose levels, protocol adherence was 55% before the questionnaire, 64% during the questionnaire (P = 0.006), and 63% afterwards. CONCLUSIONS: Providers in a specialty diabetes clinic appropriately classified patients according to glycemic control and tended to intensify therapy when indicated in most poorly controlled patients. Provider self-survey of behavior and decision making may be an effective strategy to improve adherence to management protocols. (+info)
Beneficence in general practice: an empirical investigation.
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OBJECTIVES: To study and report the attitudes of patients and general practitioners (GPs) concerning the obligation of doctors to act for the good of their patients, and to provide a practical account of beneficence in general practice. DESIGN: Semi-structured interviews administered to GPs and patients. SETTING AND SAMPLE: Participants randomly recruited from an age and gender stratified list of GPs in a geographically defined region of South Australia. The sample comprised twenty-one general practitioners and seventeen patients recruited by participating GPs. RESULTS: In practice, acting for the good of the patient not only accommodates the views of patients and GPs on expertise and knowing best, but also responds to the particular details of the clinical situation. Patients had a complex understanding of the expertise necessary for medical practice, describing a contextual domain in which they were expert, and which complemented the scientific expertise of their GPs. General practitioners identified multiple sources for their expertise, of which experience was the most significant. The role of the GP included responding to individual patients and particular clinical problems and ranged from the assumption of responsibility through to the proffering of medical advice. CONCLUSION: This study found that GPs acting for the good of their patients covered a variety of GP actions and patient preferences. Beneficence was not justified by presumed patient vulnerability or the inability of patients to understand medical problems, but furthered through a recognition of the different areas of expertise contributed by both parties to the consultation. (+info)
Attitudes of the Lebanese public regarding disclosure of serious illness.
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OBJECTIVES: To measure the preference regarding disclosure of a serious diagnosis, and its determinants, of the Lebanese public. DESIGN AND SETTING: Non-random sample survey of 400 persons interviewed in health care facilities in Beirut in 1995. RESULTS: Forty-two per cent of respondents generally preferred truth not to be disclosed directly to patients. Preference for disclosure was associated with younger age, better education and tendency to rapport-building with physicians. There were no meaningful associations between place of residence (urban/rural), level of religious practice, or religious affiliation, and preference for disclosure. CONCLUSIONS: Under one plausible interpretation, this survey suggests that the expectation for concealment will decrease as the advantage of knowledge in better coping with disease is understood by an increasingly better educated public, and that the Lebanese public will increasingly come to expect direct and full disclosure of serious diagnoses. (+info)
Thriving in a busy practice: physician-patient communication training.
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BACKGROUND: Despite growing concern about the potential impact of managed care on the physician-patient relationship, efforts to enhance the quality of communication between practicing clinicians and their patients have been limited. OBJECTIVE: To determine the effectiveness of a 1-day educational workshop. DESIGN: Clinician self-assessment of interviewing skills measured immediately before and 3 months after the workshop. SETTING: The Kaiser Permanente Medical Care Program. PARTICIPANTS: Practicing clinicians (n = 1384) in 22 workshops during a 5-year period. Nine hundred eleven participants (66% response rate) completed self-assessment questionnaires 3 months after the workshop. RESULTS: Self-assessed interviewing skills improved in all items 3 months after the workshop (P < 0.05). Clinicians also reported a decline in the proportion of visits that they characterized as frustrating. CONCLUSION: A 1-day educational intervention for large groups of practicing clinicians can improve confidence in medical interviewing skills and the ability to handle difficult encounters. (+info)
Informed consent for PSA screening: does it happen?
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CONTEXT: Screening for prostate cancer with serum prostate-specific antigen (PSA) is controversial. Ideally, patients should be aware of the potential benefits and risks related to testing. PURPOSE: To assess whether patients remembered having PSA screening and to determine whether they recalled having a discussion with their primary care provider about the pros and cons of such testing. METHODS: A questionnaire was sent to patients who had PSA screening ordered by a primary care practitioner during a 2-month period at a university-affiliated Veterans Affairs medical center. Approximately 3 months after the PSA test was done, patients were asked about their baseline health as well as their knowledge of and attitudes toward screening with PSA and treatment for prostate cancer. RESULTS: The overall response rate was 197 out of 421 (46%) patients. Among 173 eligible respondents without prostate cancer, 53 (31%) were unaware that their physician had ordered a PSA test. Among the 120 patients who were aware of receiving the test, only 56 (47%) recalled having a discussion with their primary care provider about the risks and benefits of screening. Support for the test was more common among patients who recalled having PSA screening than those who did not recall having the test (91% vs. 70%, respectively; P = 0.003). CONCLUSIONS: Patients who have PSA screening often are unable to recall relevant facts about the test and may have no knowledge of its associated risks and benefits. The role and effectiveness of obtaining verbal informed consent for PSA screening should be re-evaluated. (+info)