Geoffrey H. Gordon

Somatization in primary care: patients with unexplained and vexing medical complaints.

SummarySomatizing patients experience or express emotional discomfort and psychosocial distress as physical symptoms. Somatization occurs in a broad spectrum of illnesses, in association with a wide variety of mental disorders, including depression, anxiety, and the somatoform disorders. Primary care providers must detect and treat these patients. Diagnosis is based on positive criteria. Care rests upon conservative medical management and evaluation; a physician-patient relationship based on acceptance, caring, and trust; reinforcement of positive behaviors and elimination of destructive ones; and the gradual use of the relationship to promote healthy relating in the patient.

Effects of a physician communication intervention on patient care outcomes

OBJECTIVE: To determine whether an intervention designed to improve patient-physician communication increases the frequency with which physicians elicit patients’ concerns, changes other communication behaviors, and improves health care outcomes.DESIGN: Pretest-posttest design with random assignment of physicians to intervention or control groups.SETTING: General medicine clinics of a university-affiliated Veterans Affairs Hospital.PATZEWTS/PARTICIPANTS: Forty-two physicians and 348 continuity care patients taking prescription medications for chronic medical conditions.INTERVENTIONS: Intervention group physicians received 4.5 hours of training on eliciting and responding to patients’ concerns and requests, and their patients filled out the Patient Requests for Services Questionnaire prior to a subsequent clinic visit. Control group physicians received 4.5 hours of training in medical decision-making.MEASUREMENTS AND MAIN RESULTS: The frequency with which physicians elicited all of a patient’s concerns increased in the intervention group as compared with the control group (p=.032). Patients perceptions of the amount of information received from the physician did increase significantly (p<.05), but the actual magnitude of change was small. A measure of patient satisfaction with the physicians was high at baseline and also showed no significant change after the intervention. Likewise, the intervention was not associated with changes in patient compliance with medications or appointments, nor were there any effects on outpatient utilization.CONCLUSIONS: A low-intensity intervention changed physician behavior but had no effect on patient outcomes such as satisfaction, compliance, or utilization. Interventions may need to focus on physicians and patients to have the greatest effect.

Physician expressions of uncertainty during patient encounters

Uncertainty is inherent in clinical medicine and may contribute to variability in physician practice patterns, patient satisfaction, and exchange of information. However, research on physician disclosure of uncertainty to patients is sparse. We measured the frequency of physician expressions of uncertainty to patients using audiotapes of visits to 43 physicians by 216 continuity patients in a university-affiliated general medicine clinic. We also analyzed the audiotapes using Roter Interaction Analysis. Physicians completed Gerritys Physicians Reaction to Uncertainty scale and patients completed the Kranz Health Opinion Survey and a standardized satisfaction questionnaire. Physicians made verbal expressions of uncertainty in 71% of clinic visits. Physicians with greater self-rated reluctance to disclose uncertainty to patients made fewer expressions. Physicians who made more uncertainty expressions also used more positive talk and partnership building, and gave more information to patients. Physicians also expressed more uncertainty to patients with more education, greater desire for information, and more questions. Physician uncertainty expression were associated with greater patient satisfaction, but not independently of other physician verbal behaviors that were also associated with satisfaction.

Not the same everywhere: Patient-centered learning environments at nine medical schools

BACKGROUND: Learning environments overtly or implicitly address patient-centered values and have been the focus of research for more than 40 years, often in studies about the “hidden curriculum.” However, many of these studies occurred at single medical schools and used time-intensive ethnographic methods. This field of inquiry lacks survey methods and information about how learning environments differ across medical schools.OBJECTIVE: To examine patient-centered characteristics of learning environments at 9 U.S. medical schools.DESIGN: Cross-sectional internet-based survey.PARTICIPANTS: Eight-hundred and twenty-three third- and fourth-year medical students in the classes of 2002 and 2003.MEASUREMENTS: We measured the patient-centeredness of learning environments with the Communication, Curriculum, and Culture (C3) Instrument, a 29-item validated measure that characterizes the degree to which a medical school’s environment fosters patient-centered care. The C3 Instrument contains 3 content areas (role modeling, students’ experiences, and support for students’ patient-centered behaviors), and is designed to measure these areas independent of respondents’ attitudes about patient-centered care. We also collected demographic and attitudinal information from respondents.RESULTS: The variability of C3 scores across schools in each of the 3 content areas of the instrument was striking and statistically significant (P values ranged from .001 to .004). In addition, the patterns of scores on the 3 content areas differed from school to school.CONCLUSIONS: The 9 schools demonstrated unique and different learning environments both in terms of magnitude and patterns of characteristics. Further multiinstitutional study of hidden curricula is needed to further establish the degree of variability that exists, and to assist educators in making informed choices about how to intervene at their own schools.

Stress during internship

Mood changes of interns during the internship year were studied using the Profile of Mood States (POMS), a standardized adjective checklist. All 35 interns in the University of California, Irvine-Long Beach Medical Program completed the POMS at internship orientation and at five other times during the year. Of the six mood factors measured by the POMS, four changed significantly during the testing period. Anger-hostility scores were higher (p<0.01) in December than at orientation and remained so throughout the year. Tension-anxiety scores were higher (p<0.01) and fatigue-inertia scores were lower (p<0.01) at orientation than at any other time during the year. Vigor-activity scores were higher (p<0.01) at orientation than at the end of the year. Depression-dejection and confusion-biwilderment scores did not change significantly during the study period. Recognition of these mood changes is helpful for drawing the attention of house staff and faculty members to emotional stresses of training, and for identifying issues for discussion in intern support groups.

Evaluating a Faculty Development Course on Medical Interviewing

Since 1983, the American Academy on Physician and Patient (formerly the Task Force on Doctor and Patient) has been conducting courses using Lipkin’s model on medical interviewing for medical school faculty interested not only in teaching medical interviewing but also in improving their interviewing skills. These courses are taught over two and a half days or five days at different medical schools in the United States and abroad. The origin of these courses, their underlying philosophy, and their content are described in chapter 36. In this chapter we will review some of the findings of the evaluation process used in the first five years of the annual five-day course to further refine the present-day courses.

The teacher simulation exercise: changes in physician teaching emphasis and strategy. The SGIM Task Force on the Medical Interview.

AbstractObjective:The objective of the study was to determine the effect of a faculty development course in teaching medical interviewing on participants’ ability to provide effective feedback to interviewers. Design:The study used a non-concurrent control group design which randomized subjects into two groups before the intervention. The two groups completed different pretests; each group then completed the other group’s pre-test as its post-test. The post-course scores of one group were compared with the pre-course scores of the other group to establish differences. Setting:The research was conducted at the 1985 faculty development course sponsored by the SGIM Task Force on the Medical Interview. Participants:49 of 52 teachers of medical interviewing attending the course completed the study. Intervention:The week-long intervention consisted of a variety of educational activities which assisted the participants in defining and actively pursuing their learning objectives in interviewing, teaching, and self-awareness. Measurements and Main Results:In their assessment of two videotaped segments of initial medical visits, participants were more likely after the course to comment on the interviewer’s lack of attention to patient affect (69.0% versus 27.2%, p=0.005 in one segment) and somewhat more likely to identify teaching strategies that actively involved the interviewer (47.2% vs. 35.0%, p=0.09 in one segment). Both shifts were congruent with assessments made by course faculty. Conclusions:Faculty development can influence teachers to recognize the need to provide feedback on skills that expert teachers would emphasize. The non-concurrent control group design provides an innovative approach to common constraints in evaluating faculty development courses.

Sex and the teacher — Learner relationship in medicine

SummaryAs the numbers of women medical students, residents, and faculty increase, sexuality in teacher-learner relationships will present challenges for individuals and institutions. Ethical and legal guidelines regarding sexual harassment and contact already exist for many medical schools, hospitals, and professional organizations, as well as state and federal law. Individuals and institutions can begin to address these issues through policy development and educational sessions addressing human sexuality, communication skills, and the process of becoming a physician.

Preceptors for an introduction to clinical medicine course: needs of volunteer and full-time faculty.

Recruiting clinicians to teach bedside skills is often a challenge for Introduction to Clinical Medicine (ICM) course co-ordinations. Little data is available concerning what motivates a faculty to participate in these programmes. Better understanding of these factors might allow enhanced faculty involvement. We surveyed full-time and volunteer faculty as to what forces promote and hinder participation as preceptors for an ICM course. Results documented that both faculty groups found student interactions and teacher fulfillment their major reward, with little perceived academic or patient recognition. Personal time limitations was the greatest deterrent to participation. Assessing faculty needs has allowed focused course changes and new activities to facilitate involvement.