Patrick M. Dunn

The heart of darkness: the impact of perceived mistakes on physicians.

Objectives:To describe how physicians think and feel about their perceived mistakes, to examine how physicians’ prior beliefs and manners of coping with mistakes may influence their emotional responses, and to promote further discussion in the medical community about this sensitive issue.Design:Audiotaped, in-depth interviews with physicians in which each physician discussed a previous mistake and its impact on his or her lift. Transcripts of the interviews were analyzed qualitatively and the data organized into five topic areas: the nature of the mistake, the physician’s beliefs about the mistake, the emotions experienced in the aftermath of the mistake, the physician’s way of coping with the mistake, and changes in the physician’s practice as a result of the mistake.Participants and setting:Eleven general internists and medical subspecialists practicing at a community, university-affiliated hospital in Oregon.Results:Themes emerging from analysis of the interviews were the ubiquity of mistakes in clinical practice; the infrequency of self-disclosure about mistakes to colleagues, family, and friends; the lack of support among colleagues; the degree of emotional impact on the physician, so that some mistakes were remembered in great detail even after several years; and the influence of the physician’s professional locus of control on subsequent emotions.Conclusions:The perception of having made a mistake creates significant emotional distress for practicing physicians. The severity of this distress may be influenced by factors such as prior beliefs and perfectionism. The extent to which physicians share this distress with colleagues may be influenced by the degree of competitiveness engendered by medical training. Open discussion of mistakes should be more prominent in medical training and practice, and there should be continued research on this topic.

A Method to Communicate Patient Preferences About Medically Indicated Life-Sustaining Treatment in the Out-of-Hospital Setting

OBJECTIVE: Patient preferences for life‐sustaining treatment are frequently unknown at critical moments, which often results in clinicians providing treatment that is not medically indicated and/or may not be consistent with patient desires. A consortium of Oregon health care professionals developed the Medical Treatment Coversbeet (MTC) to standardize documentation of patient preferences in the out‐of‐hospital setting by having corresponding physician orders available at the patients location. We describe a unique process of development, evaluation, and implementation of the MTC.

The effect of resident involvement on community hospital charges

Attempts to explain the high cost of care in teaching hospitals have yielded conflicting results. This study was conducted to compare hospital charges and lengths of stay for two groups of patients: one cared for by a resident team and the other cared for by attending physicians. The study was conducted at a university-affiliated hospital in Portland, Oregon. An initial group of 5,451 admissions was examined, considering type of doctor (resident or attending), severity of illness, and patient demographic characteristics. A regression analysis revealed that total charges were similar in the two groups, but only 14% of the variance in log total charges was explained. A subgroup of 1,058 admissions in the eight most common diagnosis-related groups (DRGs) was further evaluated. In this analysis total charges for the resident patient group were 52% higher than charges for the patient group cared for by attending physicians. Forty-one per cent of the variance was explained, with type of doctor and severity of illness accounting for 5% and 10%, respectively. Further examination of one DRG indicated that additional factors not included in previous studies, such as extent of preadmission evaluation, ethical factors influencing treatment options, and patients expectations for care, may be important determinants of hospital charges. This study demonstrates that the high cost of resident care is not fully explained by currently available measures.

Parasitic infections in asymptomatic homosexual men: cost-effective screening.

The purpose of this study was to develop a cost-effective strategy for screening for enteric protozoan infections in homosexual men without gastrointestinal symptoms suggesting infection. One hundred and one homosexual men in Portland, Oregon, each submitted at least one unpurged stool sample: 91% submitted three samples each. Of these, 27% had Entamoeba histolytica, 61% had nonpathogenic protozoa with or without E. histolytica, 36% had a nonpathogen alone, and 3% had Giardia lamblia. Protozoan infection was highly associated with the practice of anilingus (p<0.05). Infection with E. histolytica correlated significantly with the presence of nonpathogenic protozoa (p<0.005). The following screening strategy was judged to be the most cost-effective: examine one sample first; if E. histolytica is found or if the sample is negative, no further investigation is required; if a nonpathogen is found, one additional sample should be obtained. This strategy had a sensitivity for E. histolytica of 85% and a cost of

Unique educational program in critical care medicine for the general internist

136 per case detected.

House staff attitudes toward psychosocial aspects of patient care

Objective: To determine the effect of a unique educational program in critical care medicine on the attitudes, knowledge, and skills of general internists who care for critically ill patients.Design: Comparison of objective assessments and self-assessments obtained before and after the one-year educational program.Setting/participants: Eighteen general internists practicing in a 350-bed university-affiliated community teaching hospital.Results: After the program, the internists felt significantly more competent in, knowledgeable about, comfortable with, and satisfied with caring for critically ill patients than they did when completing the precourse self-assessments (p<0.05). Participants felt particularly more comfortable with managing ventilator patients and leading the advanced cardiac life-support team (p<0.05). Comfort levels for other commonly performed critical care procedures did not vary. No significant change in knowledge test scores was noted from before to after the one-year program (61% vs 60%). Residents and nurses rated the internists’ overall ability in critical care medicine to be the same as that of senior medical residents. They also favorably rated the internists on humanism, teaching skills, and interpersonal interactions. Residents also appreciated the decrease in their night call because of the program.Conclusions: This unique educational program increased comfort and satisfaction of general internists caring for critically ill patients. The program was well accepted by residents and nurses because of favorable interaction with the internists and a decrease in resident night-call responsibility. This curriculum is recommended to other teaching hospitals.

A Prospective Study of the Efficacy of the Physician Order Form for Life-Sustaining Treatment

Many medical schools and residency training programs are in the process of developing and implementing new educational programs to teach medical interviewing skills and psychosocial aspects of patient care. In this process teachers may find residents less interested in the psychosocial aspects of patient care than in traditionally emphasized biomedical information. This article describes the attitudes of 120 residents from three teaching hospitals in Portland, Oregon, toward both the psychosocial aspects of patient care and the feasibility of teaching psychosocial skills to residents, as measured by a newly developed scale. Attitudes of residents are compared to those of practicing internists. The average total score for residents was significantly lower than for practicing internists (88.8 vs. 91.8, on a 115‐point scale), indicating less favorable attitudes. Resident attitudes indicated some potential challenges to teaching in this domain. For example, a significant number of residents felt that good int...