Ellen M. A. Smets

Predicting and preventing physician burnout: results from the United States and the Netherlands.

Burnout is a long-term stress reaction seen primarily in the human service professions. It is a “psychological syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment” (1). Over the past 20 years, many aspects of medical practice have changed: autonomy is declining, the status of physicians has diminished, and work pressures are increasing. Burnout is an unintended and adverse result of such changes. Burnout has been described among physicians in several countries and practice settings; in the Netherlands, physician disability insurance premiums have recently risen 20% to 30% owing to an increasing incidence of burnout and stress-related complaints (2). Paraphrasing Maslach, Wilters (3) describes burned out physicians as being angry, irritable, and impatient; “there is also an increase in absenteeism and job turnover. Decreasing productivity and practice revenue are byproducts of physician turnover.” Thus burnout can be associated with a deterioration in the physician-patient relationship and a decrease in both the quantity and quality of care. In a recent survey of health maintenance organization (HMO) physicians (4), burned out physicians were less satisfied, more likely to want to reduce their time seeing patients, more likely to order tests or procedures, and more interested in early retirement than other physicians. To better understand the interplay of the predictors of physician burnout and to develop strategies for prevention, we compared data from two large physician surveys, one in the United States (the Physician Worklife Study) and another in the Netherlands (the Dutch Study of Motivation among Medical Consultants). These data were used to construct and test a predictive model of physician burnout.

Satisfaction with the outpatient encounter: a comparison of patients' and physicians' views.

AbstractOBJECTIVE: To compare patients’ and physicians’ visit-specific satisfaction in an internal medicine outpatient setting, and to explain their respective views. DESIGN: Patients’ and physicians’ background characteristics were assessed prior to outpatient encounters. Immediately after the encounter, both patients and physicians completed a questionnaire assessing satisfaction with the visit. SETTING: The outpatient division of an academic teaching hospital. PARTICIPANTS: Thirty residents and specialists in general internal medicine, rheumatology, and gastroenterology, and 330 patients having a follow-up appointment with one of these physicians. MEASUREMENTS AND MAIN RESULTS: Patients’ and physicians’ visit-specific satisfaction was assessed using 5 Visual Analogue Scales (0 to 100). Patients’ overall satisfaction was higher than physicians’ satisfaction (mean 81 vs. 66), and correlation of patients’ and physicians’ overall satisfaction with the specific visit was medium sized (r=.28, P<.001). Patients’ satisfaction ratings were associated with their previsit self-efficacy in communicating with their physician (P<.001) and with visiting a female physician (P<.01). Physicians’ satisfaction was associated with patients’ higher educational level (P<.05), primary language being Dutch (P<.001), better mental health (P<.05), and preference for receiving less than full information (P<.05). CONCLUSIONS: In an outpatient setting, patients’ visit-specific satisfaction ratings were substantially higher than, and only moderately associated with, physicians’ ratings of the same visit. The dissimilar predictors explaining patients’ and physicians’ satisfaction suggest that patients and physicians form their opinion about a consultation in different ways. Hence, when evaluating outpatient encounters, physicians’ satisfaction has additional value to patients’ satisfaction in establishing quality of care.

Randomized placebo‐controlled trial of testosterone replacement in men with mild Leydig cell insufficiency following cytotoxic chemotherapy

OBJECTIVE Testosterone deficiency is associated with significant morbidity, and androgen replacement in overt hypogonadism is clearly beneficial. However, there are few data concerning the response to therapy in young men with mild testosterone deficiency.

How response shift may affect the measurement of change in fatigue

If patients experience extreme fatigue during treatment, they may judge the level of fatigue following this experience differently from how they would have judged it before. This change in internal standard is referred to as a response shift. We explored whether a response shift might have occurred in patients receiving radiotherapy (n = 199). Fatigue was assessed before and after radiotherapy. Following completion of the post-test, a thentest was administered where patients had to provide a renewed judgment of their pre-treatment level of fatigue. Response shift was assessed by the mean difference between the pre-test and thentest scores. Comparing the thentest with the pretest scores, patients retrospectively minimized their pre-treatment level of fatigue. The thentest-post-test difference was significant, whereas the conventional pretest-post-test difference was not. These results are in line with the occurrence of a response shift. Additional hypotheses regarding response shift were partially supported. It is concluded that the potentially large implications of response shift justify further research.

Fatigue, sexual function and mood following treatment for haematological malignancy: the impact of mild Leydig cell dysfunction.

Fatigue, sexual dysfunction, anxiety and depression are all more common in patients who have previously been treated with cytotoxic chemotherapy and radiotherapy (XRT) for haematological malignancies. Following therapy, a significant proportion of men have biochemical evidence of Leydig cell dysfunction, defined by a raised luteinizing hormone level in the presence of a low/normal testosterone level. We postulated that mild testosterone deficiency may account for some of the long-term side-effects of treatment, and we have therefore assessed fatigue, mood and sexual function by questionnaire in 36 patients with Leydig cell dysfunction (group 1), and also in a group of 30 patients (group 2) with normal hormone levels who underwent the same treatment for cancer. There was no significant difference in anxiety and depression scores between the two groups although anxiety scores were higher than those previously reported for normal men. Eighty-seven per cent of group 2 were sexually active compared with only 69% of group 1 (P = 0.1), and patients in group 1 engaged less in sexual activity than those in group 2 (mean of 1.8 times per week compared with 3.2 times per week;P = 0.02) Fatigue scores were significantly higher in both groups compared with normal men, but there were no significant differences in any of the fatigue subscales between the two groups. We conclude that mild Leydig cell insufficiency following treatment with cytotoxic chemotherapy ± XRT is not associated with higher levels of fatigue and anxiety but may result in reduced sexual function. These results do not provide a convincing argument that androgen replacement therapy is mandatory to improve quality of life in the majority of these patients, although it may be beneficial in a minority. To establish criteria for selection of patients for a trial of androgen therapy a randomized placebo-controlled study will be necessary.

Familial disease with a risk of sudden death: A longitudinal study of the psychological consequences of predictive testing for long QT syndrome

BACKGROUND Since 1996, in the Netherlands, cardiac and molecular screening has been performed in families with the long QT syndrome, a potentially life-threatening but treatable cardiac arrhythmia syndrome. The psychological consequences of predictive cardiac and molecular screening in these families are relatively unknown. OBJECTIVE A psychological study was initiated to investigate the extent and course of distress caused by this new form of predictive genetic testing. METHODS We carried out a prospective study to assess the extent and course of disease-related anxiety and depression, caused by predictive genetic testing, in applicants and their partners from the time of first consultation until 18 months after the disclosure of the result of genetic testing. RESULTS Seventy-seven applicants and 57 partners were investigated for measures of distress in 3 assessments. Those individuals who received an uncertain electrocardiogram result seemed especially vulnerable for distress, at least in the short term. The distress levels in the whole group of applicants were largely restored within 18 months. However, the disease-related anxiety scores in carriers remained relatively increased at long term. As compared with partners of noncarriers, partners of mutation carriers had higher levels of disease-related anxiety at all 3 assessments. CONCLUSION Predictive testing for long QT syndrome consisting of cardiologic testing followed by molecular testing leads to distress, especially in carriers with an uncertain electrocardiogram and their partners at first visit. These distress levels return to normal at long term. However, for carriers with an uncertain electrocardiogram, the incidence of clinically relevant distress was high, most probably also caused by the consequences of having the disease.

Genetic counseling and cardiac care in predictively tested hypertrophic cardiomyopathy mutation carriers: the patients' perspective

Hypertrophic cardiomyopathy (HCM) is a common hereditary heart disease associated with sudden cardiac death. Predictive genetic counseling and testing are performed using adapted Huntington guidelines, that is, psychosocial care and time for reflection are not obligatory and the test result can be disclosed by telephone or mail. Proven mutation carriers detected by predictive DNA testing are advised to undergo regular cardiac follow‐up according to international guidelines. We evaluated the opinion of 143 predictively tested HCM mutation carriers on received cardiogenetic care using questionnaires (response rate 86%). Predictive genetic counseling and DNA testing were evaluated on four domains: information provision, satisfaction with counseling, social pressure in DNA testing and regret of DNA testing. Opinions on cardiac follow‐up were assessed pertaining to communication, nervous anticipation, reassurance, and general disadvantages. Genetic counseling was valued positively and only four carriers would rather not have known that they were a mutation carrier. A majority received their DNA test result by mail or telephone, and almost all were satisfied. Only 76% of carriers received regular cardiac follow‐up. Those who did, had a positive attitude regarding the cardiac visits. General disadvantages of the visits were valued as low, especially by older carriers, men and carriers with manifest HCM. We conclude that our adapted Huntington guidelines are well accepted and that cardiogenetic care is generally appreciated by predictively tested HCM mutation carriers. To better understand the cause of the substantial portion of mutation carriers not receiving regular cardiac follow‐up, although recommended in international guidelines, further research is needed.

Medical specialists' patient-centered communication and patient-reported outcomes.

Background:Physicians’ patient-centered communication in the medical consultation is generally expected to improve patient outcomes. However, empirical evidence is contradictory so far, and most studies were done in primary care. Objective:We sought to determine the association of specialists’ patient-centered communication with patient satisfaction, adherence, and health status. Methods:Residents and specialists in internal medicine (n = 30) and their patients (n = 323) completed a questionnaire before a (videotaped) follow-up encounter. Patients’ satisfaction was assessed immediately after the consultation and their self-reported treatment adherence, symptoms, and distress 2 weeks later. Specialists’ patient-centered communication was assessed by coding behaviors that facilitate or rather inhibit patients to express their perspective. Patient participation was assessed by determining their relative contribution to the conversation and their active participation behavior. Outcomes were assessed using standard questionnaires. Analyses accounted for relevant patient, visit and physician characteristics. Results and Conclusions:Medical specialists’ facilitating behavior was associated with greater satisfaction in patients who were less confident in communicating with their doctor. Patient-centered communication was not associated with patients’ health status or adherence in general, but facilitating behavior was positively related to the adherence of patients with a foreign primary language. In general, patients appeared to be more satisfied after an encounter with a more-facilitating and a less-inhibiting physician, but these associations diminished when controlling for background characteristics. We conclude that the absence of strong associations between patient-centered communication and patient-reported outcomes may be explained by medical specialists being responsive to patients’ characteristics.

Predictive Genetic Testing for Cardiovascular Diseases: Impact on Carrier Children

We studied the experiences of children identified by family screening who were found to be a mutation carrier for a genetic cardiovascular disease (Long QT Syndrome (LQTS), Hypertrophic Cardiomyopathy (HCM), Familial Hypercholesterolemia (FH)). We addressed the (a) manner in which they perceive their carrier status, (b) impact on their daily lives, and (c) strategy used to cope with these consequences. Children (aged 8–18) who tested positive for LQTS (n = 11), HCM (n = 6) or FH (n = 16), and their parents participated in semi‐structured audiotaped interviews. Interview topics included illness perception, use of medication, lifestyle modifications, worries, and coping. Each interview was coded by two researchers. The qualitative analysis was guided by Leventhals model of self‐regulation. The children were overall quite articulate about the disease they were tested for, including its mode of inheritance. They expressed positive future health perceptions, but feelings of controllability varied. Adherence and side‐effects were significant themes with regard to medication‐use. Refraining from activities and maintaining a non‐fat diet were themes concerning lifestyle modifications. Some children spontaneously reported worries about the possibility of dying and frustration about being different from peers. Children coped with these worries by expressing faith in the effectiveness of medication, trying to be similar to peers or, in contrast, emphasizing their “being different.” Children generally appeared effective in the way they coped with their carrier status and its implications. Nevertheless, dealing with the daily implications of their condition remains difficult in some situations, warranting continued availability of psychosocial support.

The information needs of new radiotherapy patients: how to measure? Do they want to know everything? And if not, why?

PURPOSE To establish 1) further psychometric properties of the information preference for radiotherapy patients scale (IPRP); 2) what information new radiotherapy patients want to receive; 3) which patients have a lower information need. METHODS AND MATERIALS Eligible patients (n = 159; response rate 54%) of 15 radiation oncologists completed the IPRP and provided background characteristics before their first radiotherapy consultation. Exclusion criteria were: age <18 years, having undergone radiotherapy before, unable to read and write Dutch, cognitive problems or a brain tumor. RESULTS Reliability (Cronbachs alpha 0.84-0.97) and concurrent validity (r from .39 to .57, p < 0.001) of the subscales of the IPRP were good. New radiotherapy patients want extensive information about their disease, treatment, procedures, side effects, and prognosis (mean scores between 4.1 and 4.4 on a scale from 1 to 5) but less information about psychosocial issues (mean = 3.4). Patients who are older and male, have lung or rectal cancer, more difficulty understanding and a higher trait anxiety level, need less information. CONCLUSIONS The IPRP can reliably and validly address information needs of patients undergoing radiation treatment. Most new radiotherapy patients want much information. Yet, information giving should be tailored according to their background, understanding and anxiety.