Richard Steiner

Physician treatment of men and women patients: sex bias or appropriate care?

This paper considers medical care given by physicians to men and women in the United States. It asks how often significant sex differences in care occur, and if these differences are attributable to medically relevant factors or not. Sex differences in diagnostic services, therapeutic services, and dispositions for follow-up are studied for All Visits, 15 major groups of complaints, and 5 specific complaints (fatigue, headache, vertigo/dizziness, chest pain, and back pain). Data are from the 1975 National Ambulatory Medical Care Survey (NAMCS). The analysis reveals that medical care is often similar for men and women, but a sizable number of significant sex differences occur (about 30 to 40 per cent of the services and dispositions studied), and they tend to show more medical care for women. Most of the differences persist even after controlling for medically relevant factors (patient age, seriousness of problem, diagnosis, prior visit status, and reasons for visit). Notably, women still receive more total and extensive services, and more laboratory tests, blood pressure checks, drug prescriptions, and return appointments for many complaint groups. They receive more services for back pain and headaches and more follow-up plans for vertigo/dizziness and back pain. Remaining sex differences may be due to missing medical factors, patient requests for care, patient distress and needs for nurturance, and physician sex bias. In contrast to a recent San Diego study,1 national data show few significant sex differences in the extent and content of diagnostic services given for five common complaints.

Measuring comfort in caregivers and patients during late end-of-life care:

The purpose of this study was to test several formats of end-of-life comfort instruments for patients and closely involved caregivers. Kolcaba’s Comfort Theory was the theoretical framework utilized. Different response formats for two end-of-life (EOL) comfort questionnaires (for patients and caregivers, respectively), and horizontal and vertical visual analog scales for total comfort (TC) lines were compared in two phases. Evaluable data were collected from both members of 38 patient-caregiver dyads in each phase. Suitable dyads were recruited from two hospice agencies in northeastern Ohio. Cronbach’s alpha for the EOL comfort questionnaire (six response Likert-type format) tested during phase I for patients was .98 and for caregivers was .97. Test-retest reliability for the vertical TC line tested during phase I for patients was .64 and for caregivers was .79. The implications of this study for nursing practice and research are derived from the American Nursing Association (ANA) position statement about EOL care, which states that comfort is the goal of nursing for this population. These instruments will be useful for assessing comfort in actively dying patients and comfort of their caregivers as well as for developing evidence-based practice for this population.

Efficacy of Hand Massage for Enhancing the Comfort of Hospice Patients

There is a need to develop and test interventions for patients near end of life that are comforting, easy to learn and administer, and require little effort on the part of recipients. This experimental study tested the efficacy of bilateral hand massage for enhancing hospice patients’ holistic comfort as measured with the Hospice Comfort Questionnaire (HCQ). We hypothesized that, over 3 time points, patients who received hand massage would have higher comfort and less symptom distress than a comparison group. Participants were randomized into treatment (received the intervention twice weekly for 3 weeks) or comparison groups (received the intervention once at the study’s end). Findings indicated that patients receiving hand massage had increased comfort over time, while symptom distress remained flat in both groups. However, findings were insignificant. Ethical and practical issues experienced in this study are discussed.

Prescribing drugs to men and women.

This article examines how often physicians prescribe therapeutic drugs to men and women who present the same complaints or receive the same diagnoses. Data are from the 1975 National Ambulatory Medical Care Survey and pertain to visits made by U.S. adults to office-based physicians that year. For most common complaints and diagnoses, women receive prescriptions more often than men do. The differences are on the small side (1 to 18% more of womens visits result in prescriptions than mens), but they are very persistent across a wide variety of health problems. Medical differences between men and women patients do not explain this. Controlling for medically relevant factors (patient age, seriousness of the problem, presence of an illness/injury or not, prior visit status, acute vs. chronic problem), the sex differences persist. Women are especially likely to get prescriptions during visits for weight gain/obesity and visits classed as observation without need for further care. The results suggest that psychosocial factors may help explain why women receive prescriptions more often during office visits than men do. Those factors could stem from patient behaviors such as overt requests for drug therapy or from physician behaviors such as sex-biased prescribing.

Empirical Evidence for the Nature of Holistic Comfort

The nursing outcome of holistic comfort encompasses physical, psychospiritual, social, and environmental aspects of human nature. The primary purpose of this study was to test four propositions about the nature of comfort: (a) Comfort has equal proportions of state and trait characteristics; (b) comfort is sensitive to changes over time; (c) when subjects are exposed to an effective intervention, they demonstrate differences in comfort that increase in a linear way compared to a control group; and (d) the whole (total comfort) is greater than the sum of its parts (relief plus ease plus transcendence). A secondary purpose of this study was to present preliminary concurrent validity between two types of comfort instruments, a traditional questionnaire with a Likert-type format and visual analog scales. Findings were positive for all theoretical propositions and moderate concurrent validity between the Radiation Therapy Comfort Questionnaire and the visual analog scale for total comfort was demonstrated.

Using cognitive strategies to enhance bladder control and comfort.

Compromised urinary bladder syndrome (CUBS), a combination of frequency and incontinence, causes multiple discomforts for community-dwelling adults. A holistic intervention--audiotaped cognitive strategies--was designed to augment the effects of an educational program designed to treat CUBS. CUBS was operationalized with a voiding diary, and comfort related to bladder health was operationalized in a questionnaire. In this quasi-experimental design the outcomes were measured at four time points. Repeated measures multivariate analyses of variance and nonparametric analyses were conducted to assess differences between the two groups. Results indicated that the treatment group had more comfort and improved CUBS compared with the control group.

Hemispheric involvement in shadowing vs. interpretation: A time-sharing study of simultaneous interpreters with matched bilingual and monolingual controls

A time-sharing study used shadowing and interpretation/paraphrasing tasks to evaluate lateralization in professional interpreters individually matched to bilingual and monolingual controls. A two-step multivariate general linear model procedure was used to determine lateralized effects and extent of disruption produced by the tasks. Results revealed the monolingual group to be left lateralized for both tasks, but the two bilingual groups were lateralized in the LH only for shadowing. The monolingual group was significantly different from the bilingual groups in the pattern of hand asymmetry for interpretation/paraphrasing. The findings replicate outcomes of prior repeated measures analysis of variance procedures on percentage of change scores. However, new information is added by the more refined analysis. The findings are also discussed in terms of previous laterality studies using similar tasks and subject samples.

Upper-Extremity Stroke Therapy Task Discrimination Using Motion Sensors and Electromyography

Brain injury resulting from stroke often causes upper-extremity motor deficits that limit activities of daily living. Several therapies being developed for motor rehabilitation after stroke focus on increasing time spent using the extremity to promote motor relearning. Providing a novel system for user-worn therapy may increase the amount and rate of functional motor recovery. A user-worn system comprising accelerometers, gyroscopes, and electromyography amplifiers was used to wirelessly transmit motion and muscle activity from normal and stroke subjects to a computer as they completed five upper-extremity rehabilitation tasks. An algorithm was developed to automatically detect the therapy task a subject performed based on the gyroscope and electromyography data. The system classified which task a subject was attempting to perform with greater than 80% accuracy despite the fact that those with severe impairment produced movements that did not resemble the goal tasks and were visually indistinguishable from different tasks. This developed system could potentially be used for home-therapy compliance monitoring, real-time patient feedback and to control therapy interventions.

Comparison of a healing touch, coaching, and a combined intervention on comfort and stress in younger college students.

Three nursing interventions to increase total comfort and reduce stress-related events in young college students experiencing stress were compared. Healing Touch, coaching, and a combination of both, were compared to a waitlist. On comfort and stress, Healing Touch had better immediate results, while coaching had better carryover effects.

Clinically Suspected Scaphoid Fractures in Children

Purpose: Scaphoid fractures are often missed in children because of their rarity and difficulty with radiographic diagnosis. Children are often treated for clinically suspected scaphoid fractures although there is no radiographic evidence for fracture on initial evaluation. The 2-fold purpose of this study is (1) to determine how many clinically suspected pediatric scaphoid fractures later became radiographically evident fractures and (2) to identify physical examination findings that suggest a scaphoid fracture when present at initial evaluation. Methods: We performed separate retrospective and longitudinal reviews of children younger than 16 years referred to orthopaedics with traumatic wrist pain from January 1995 to April 2002. A total of 104 cases with high clinical suspicion but no radiographic evidence of scaphoid fracture on initial examination were included. Patients were followed until discharge to determine if they later demonstrated a confirmed fracture. In the longitudinal arm, 7 specific examination findings were recorded. Simple and multiple logistic regressions were used to analyze the data. Results: Thirty-one (30%) of the 104 wrists with no initial radiographic evidence of fracture had a radiographically evident scaphoid fracture at follow-up. In the longitudinal arm (n = 41), the following 3 findings were statistically significant predictors of scaphoid fracture: volar tenderness over the scaphoid (P = 0.010), pain with radial deviation (P = 0.001), and pain with active wrist range of motion (P = 0.015). Presence of any of these findings was associated with a higher likelihood of scaphoid fracture. Conclusion: A high percentage (30%) of clinically suspected scaphoid fractures in children became radiographically evident fractures at follow-up. Volar scaphoid tenderness, radial deviation pain, and pain with active wrist range of motion can be used as signs to increase suspicion for eventual fracture. We recommend that all clinically suspected pediatric scaphoid fractures be immobilized with repeat radiographs and a clinical examination at 2 weeks. Level of Evidence: II