Jack Ende

Measuring patients' desire for autonomy: decision making and information-seeking preferences among medical patients

An instrument for measuring patients’ preferences for two identified dimensions of autonomy, their desire to make medical decisions and their desire to be informed, was developed and tested for reliability and validity. The authors found that patients prefer that decisions be made principally by their physicians, not themselves, although they very much want to be informed. There was no correlation between patients’ decision making and information-seeking preferences (r=0.09; p=0.15). For the majority of patients, their desire to make decisions declined as they faced more severe illness. Older patients had less desire than younger patients to make decisions and to be informed (p<0.0001 for each comparison). However, only 19% of the variance among patients for decision making and 12% for information seeking could be accounted for by stepwise regression models using sociodemographic and health status variables as predictors. The conceptual and clinical implications of these findings are discussed. Key words: patient autonomy; decision making; survey research.

What If Osler Were One of Us

Master, mentor, supervisor, facilitator, or all of the above—somewhere in this list lies the role of the inpatient teacher, perhaps the most intense assignment clinician-educators are asked to assume. Always challenging, inpatient teaching currently must meet requirements and regulations that did not even exist years ago. Todays handbook of inpatient teaching includes chapters written by (1) the Accreditation Council on Graduate Medical Education (ACGME) governing training experiences and working conditions for residents; (2) managed care organizations and hospital utilization committees establishing guidelines for admissions, length of stay, and utilization of diagnostic tests, consultations, and other resources; and (3) the Health Care Financing Administration (HCFA) and other third-party payers setting forth requirements that affect the level of the attending physicians’ involvement in patient care and the allocation of their time, and at least indirectly, housestaff responsibility and learning.

Enhancing learning during a clinical clerkship

Third-year clerkships, organized around clinical experiences, may provide students with an uneven or narrowly focused fund of clinical knowledge. This paper describes the results of a comparative trial in which a structured curriculum, based on learning objectives, was introduced into an internal medicine clerkship at one of three teaching hospitals of a single medical school; the other two hospitals, providing similar patient care experiences, were used for comparison purposes. Students who did their clerkship at the hospital using the structured curriculum scored significantly higher on the Medicine section of the National Board Part II examination when scores were adjusted for past academic performance. The structured curriculum was very well received and, according to student perceptions, achieved the goal of expanding their basic clinical knowledge beyond that derived from reading only in connection with patient care. These results support the use of curricular guidelines and objectives as a means of enhancing students’ cognitive experience during clinical clerkships.

The Downsizing of Internal Medicine Residency Programs

A variety of forces are converging to reduce the number of internal medicine residency positions offered in this country. This reduction, referred to as downsizing, has been proposed as the solution to several of the problems facing internal medicine. We examine the forces that underlie the current enthusiasm for downsizing; we consider the alternative strategies by which downsizing might be implemented; and we consider the implications of these alternatives on different groups of stakeholders. Although downsizing may represent a legitimate approach to real problems, any mechanism to reduce the number of training positions in internal medicine will have broad implications for medical education and patient care well into the next century. Special efforts must be taken to ensure that downsizing will not exacerbate the existing problem of overspecialization and limited access to care.

Pruritus: a practical approach.

Pruritus is usually caused by a primary disorder of the skin, but can also be caused by a systemic disease (Table 1). Some dermatologic conditions that cause pruritus can be inconspicuous or nonspecific (Table 2), while others are usually apparent on physical examination (Table 3). Classification of pruritus as localized (Fig. 1) vs. generalized (Fig. 3) can be helpful in arriving at a correct diagnosis. The history and physical examination are the most important diagnostic tools, though laboratory testing for systemic disease may be necessary. In refractory cases, one should consider occult systemic disease (such as malignancy), psychiatric disease (especially depression), and HIV infection. Subsequent referral to a dermatologist may be indicted. When treatment of the underlying cause of pruritus is not possible, antihistamines and topical agents (menthol, phenol, and/or pramoxine) can be helpful.

Our Continuing Interest in Manuscripts About Education

ConclusionsJGIM would like to receive more manuscripts with an educational focus that convey important and useful information to its readers. TheJournal is committed to education scholarship and to keeping its readers informed in areas related to instruction, evaluation, and curriculum. The education manuscripts theJournal receives now are variable in quality;JGIM readers deserve more. The editors welcome your comments and your manuscripts.

Evaluation of liver size by physical examination

THE CLINICAL DETERMINATION of l iver size has been perfo rmed by physicians for centuries. Percussion and palpat ion have been the most popu la r techniques, and lately the scratch test has gained notice. It was not until the 1960s, however , that studies were conduc ted to test the intraand interobserver reliabilities, and to determine normat ive standards for the cl inical ly de te rmined liver span. Later, l iver size obta ined by physical examination was compa red wi th actual size at au topsy and with size de te rmined by radiologic techniques. In this article we call at tention to those studies that p rov ide information about the bedside de tec t ion of hepat ic enlargement . Our rev iew is based on a MEDLINE search of articles publ i shed be tween 1987 and 1992 and the refe rence lists of those articles. The purpose of this art icle is to enable clinicians to refine their t echn ique for detect ing and fol lowing the progression of hepat ic enlargement. In clinical pract ice, hepat ic en la rgement is of ten gauged by whe the r the liver is palpable , and by the n u m b e r of finger breadths or cent imeters the l iver edge is felt b e l o w the costal margin. Numerous investigators, however , have demonst ra ted l iver palpabi l i ty in normal populat ions . Palmer 1 in 1958 evaluated 1,000 mil i tary personnel receiving rout ine physical examinations. The subjects had no history of liver disease and normal l iver funct ion tests. Fifty-seven percen t of his s tudy populat ion had a pa lpable l iver edge at or b e l o w the right costal margin, and 28% had the liver edge pa lpa ted two or more cent imeters b e l o w the right costal margin at peak inspiration. Riemenschneider and Whalen 2 found that 14 of 47 patients had a pa lpable l iver on examinat ion but only six patients had an enlarged l iver at autopsy. Naftalis and Leevy 3 evaluated l iver size by physical examination, nuclear scintiscans, and autopsy and found no rela t ionship be tween the projec t ion of the l iver be low the thoracic cage and overall l iver size. They found the greatest d iscrepancy in patients wi th emphysema or chest deformit ies . Palpabil i ty of the l iver edge, therefore, appears to be an inaccurate measure of l iver size. Longitudinal l iver span, as opposed to palpabi l i ty of the lower liver edge, has also been assessed as a physi-