E. Gil Boyer

The good news about giving bad news to patients.

BACKGROUND: There are few data available on how physicians inform patients about bad news. We surveyed internists about how they convey this information.METHODS: We surveyed internists about their activities in giving bad news to patients. One set of questions was about activities for the emotional support of the patient (11 items), and the other was about activities for creating a supportive environment for delivering bad news (9 items). The impact of demographic factors on the performance of emotionally supportive items, environmentally supportive items, and on the number of minutes reportedly spent delivering news was analyzed by analysis of variance and multiple regression analysis.RESULTS: More than half of the internists reported that they always or frequently performed 10 of the 11 emotionally supportive items and 6 of the 9 environmentally supportive items while giving bad news to patients. The average time reportedly spent in giving bad news was 27 minutes. Although training in giving bad news had a significant impact on the number of emotionally supportive items reported (P < .05), only 25% of respondents had any previous training in this area. Being older, a woman, unmarried, and having a history of major illness were also associated with reporting a greater number of emotionally supportive activities.CONCLUSIONS: Internists report that they inform patients of bad news appropriately. Some deficiencies exist, specifically in discussing prognosis and referral of patients to support groups. Physician educational efforts should include discussion of prognosis with patients as well as the availability of support groups.

Physicians' experiences with patients who transgress boundaries.

AbstractBACKGROUND: Boundary violations have been discussed in the literature, but most studies report on physician transgressions of boundaries or sexual transgressions by patients. We studied the incidence of all types of boundary transgressions by patients and physicians’ responses to these transgressions. METHODS: We surveyed 1,000 members of the Society of General Internal Medicine (SGIM) for the number of patient transgressions of boundaries which had occurred in the previous year. Categories were created by the investigators based on the literature. Physicians picked the most important transgression, and then were asked about their response to the transgression and its effect on the patient-physician relationship. Attitudinal questions addressed the likelihood of discharging patients who transgressed boundaries. The impact of demographic variables on the incidence of transgressions was analyzed using analysis of variance. RESULTS: Three hundred thirty (37.5%) randomly selected SGIM members responded to the survey. Almost three quarters of the respondents had patients who used their first name, while 43% encountered verbal abuse, 39% had patients who asked personal questions, 31% had patients who were overly affectionate, and 27% encountered patients who attempted to socialize. All other transgressions, including physical abuse and attempts at sexual contact, were uncommon. Only gender affected the incidence of transgressions; female physicians encountered more personal questions (P=.001), inappropriate affection (P < .005), and sexually explicit language (P < .05) than male physicians and responded more negatively to boundary transgressions. Respondents dealt with transgressions by discussion with the patient or colleagues or by ignoring the incident, but such transgressions generally had a negative impact on the relationship. Most physicians would discharge patients who engaged in physical abuse or attempts at sexual contact, but were more tolerant of verbal abuse and overly affectionate patients. CONCLUSIONS: Boundary transgressions by patients is common, but usually involves more minor infractions. Female physicians are more likely to encounter certain types of transgressions. The incidence and outcomes of such transgressions are important in assisting physicians to deal effectively with this issue.

Cardiopulmonary resuscitation. Values and decisions--a comparison of health care professionals.

The authors studied the effect of various patient factors (biomedical, mental status, and psychosocial) on the decision to perform cardiopulmonary resuscitation by internal medicine house staff and registered nurses. Clinical vignettes were utilized to assess the likelihood of initiation of cardiopulmonary resuscitation (CPR) by the respondents. In most cases, these factors had similar significant effects on decisions to initiate CPR by both physicians and nurses. However, some differences in the likelihood of performing CPR were found between the physician and nurse populations, particularly in the areas of mental status and institutionalization. Dementia, mental retardation, and nursing home status all caused residents to be significantly less likely to initiate CPR than nurses (P < 0.001). This study demonstrates that biomedical, mental status, and psychosocial patient factors have a significant impact on the decision to initiate CPR by both internal medicine residents and nurses. These decisions apparently are rooted in similar criteria, although the basis for the differences between the two groups warrants further study.

Residents' decisions to breach confidentiality

This study assessed variables involved in physician decisions to breach confidentiality in cases of patients’ self-reported past crimes. Seventy internal medicine residents completed a questionnaire containing case vignettes of patients’ self-reports of crimes; likelihood of informing the police was ascertained. Results were analyzed according to the type and cost of the crime, previous criminal record, patient characteristics, and intent of the patient to commit future crimes. Results also were analyzed by postgraduate year of the resident. Patient characteristics of race and socioeconomic status had no effect on the decision (p<0.122 and p 0.182), although age did (p<0.001). Reports of past violence (p<0.001), previous criminal record (p<0.001) and high-cost crime (p<0.007) increased the likelihood of breaching confidentiality. Future intent affected the decision (p<0.005), but less than reports of past violence. No differences were seen among postgraduate years of respondents (p<0.873). Residents base decisions to breach confidentiality on factors other than the future intent of specific violence. This finding has legal and ethical implications.

Telling patients about the diagnosis of HIV infection

This study used a questionnaire to examine how patients in the HIV/AIDS Clinic at a Department of Veterans Affairs hospital were told of their diagnosis, by whom, and to what degree they were given emotional and educational support. Nearly 17% of patients were informed by someone not in the health professions (often military personnel), and 27% of patients were notified in a nonprivate setting. Forty-seven percent indicated they received little or no educational support at the time of diagnosis, while 39% received little or no emotional support. Educational and emotional support for patients at the time of HIV diagnosis may be lacking.