Sandra K. Joos

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.

Is constipation associated with decreased physical activity in normally active subjects

BACKGROUND:The effectiveness of physical activity in the management of constipation remains controversial. We examined the associations among physical activity, constipation, and quality of life (QoL) in a population of employed adults to determine whether the risk of constipation is related to physical activity.METHODS:A total of 1,069 employees (age range 24–77) of the Veterans Affairs (VA) Black Hills Health Care System were mailed validated questionnaires (response rate 72%), inquiring about bowel habits, QoL (SF 36), and physical activity (modified Baecke questionnaire). Constipation was defined using the Rome I criteria.RESULTS:One hundred and forty (19.4%, 95% CI 16.2–22.4) employees reported constipation. The average total physical activity and all subscales of physical activity were not significantly different in subjects with and without constipation (all p≥ 0.2). Subjects with constipation had lower QoL scores than subjects without constipation, and physical activity was positively correlated with physical functioning and health perception.CONCLUSION:Physical activity appears to be unrelated to the risk of constipation in employed adults, but higher physical activity was associated with improved QoL. Recommendations to increase physical activity may not alter symptoms of constipation but may improve overall well-being.

Symptom factor analysis, clinical findings, and functional status in a population-based case control study of Gulf War unexplained illness.

Few epidemiological studies have been conducted that have incorporated clinical evaluations of Gulf War veterans with unexplained health symptoms and healthy controls. We conducted a mail survey of 2022 Gulf War veterans residing in the northwest United States and clinical examinations on a subset of 443 responders who seemed to have unexplained health symptoms or were healthy. Few clinical differences were found between cases and controls. The most frequent unexplained symptoms were cognitive/psychological, but significant overlap existed with musculoskeletal and fatigue symptoms. Over half of the veterans with unexplained musculoskeletal pain met the criteria for fibromyalgia, and a significant portion of the veterans with unexplained fatigue met the criteria for chronic fatigue syndrome. Similarities were found in the clinical interpretation of unexplained illness in this population and statistical factor analysis performed by this study group and others.

Abdominal Bloating in Employed Adults: Prevalence, Risk Factors, and Association With Other Bowel Disorders

BACKGROUND AND AIMS:Bloating is common, but its significance as a marker of underlying disease has not been defined. We report on risk factors for bloating, its relationship to physical activity and quality of life (QOL), and its predictive value for functional bowel disorders.METHODS:This is a cross-sectional population-based study of 1,069 employees of the Veterans Affairs Black Hills Health Care System. The validated Bowel Disease Questionnaire was used to identify subjects with abdominal bloating and other bowel disorders. The association of bloating with QOL was assessed using the SF36 (Short-Form 36) questionnaire. Physical activity was assessed using the modified Baecke questionnaire.RESULTS:The response rate was 72% (723 of 1,069). Bloating was reported by 21% of all subjects (95% confidence interval [CI] 17.7–23.7), 64% with irritable bowel syndrome (IBS), 35% with non-IBS constipation, 23% with non-IBS diarrhea, and 42% with dyspepsia. Functional bloating (i.e., bloating in the absence of other bowel disorders) was reported by 7% of subjects (95% CI 5.2–9.0). Of those with bloating, 28% had IBS, 25% non-IBS constipation, 8% non-IBS diarrhea, and 30% dyspepsia. The positive and negative predictive values of bloating in the diagnosis of functional bowel disorder were 66% and 87%, respectively. The only risk factors were smoking and high-dose aspirin. Bloating was not associated with physical activity. QOL on all subscales of SF36 was lower in subjects with bloating than those without bloating.CONCLUSIONS:Bloating is a common symptom in otherwise healthy adults, and is often associated with but not predictive of functional bowel disorders. Smoking and high-dose aspirin are associated with bloating while physical activity is not.

Chronic fatigue in a population-based study of Gulf War veterans

Abstract Fatigue has been associated with illness in veterans of the Gulf War; however, few studies have confirmed self-reported fatigue by using clinical evaluation, and symptomatic veterans have not been evaluated with established criteria for Chronic Fatigue Syndrome (CFS). The authors describe the frequency and clinical characteristics of CFS in a sample of veterans residing in the northwestern United States. The sample was selected randomly from U.S. Department of Defense databases of troops deployed to southwest Asia during the Gulf War. The selected individuals were invited to participate in a clinical case-control study of unexplained illness. Of 799 survey respondents eligible for clinical evaluation, 178 had fatigue symptoms. Of the 130 veterans who were evaluated clinically, 103 had unexplained fatigue, and 44 veterans met the 1994 U.S. Centers for Disease Control criteria for CFS. In this population, the authors estimated a minimum prevalence of any unexplained fatigue to be 5.1%, and of CFS to be 2.2%. The estimated prevalence was greater among females than among males. Cases were similar to healthy controls, as determined by laboratory tests and physical findings. In comparison to several clinical studies of CFS patients, the authors of this study found a lower proportion of veterans who reported a sudden onset of symptoms (19%) vs. a gradual onset (50%). Although it has previously been suggested that veterans of the Gulf War suffer from higher rates of chronic fatigue than the general population, the study results described herein–on the basis of clinical examination of a population-based sample of veterans–actually indicate that an increased rate may indeed exist. Gulf War veterans with unexplained fatigue should be encouraged to seek treatment so that the impact of these symptoms on overall quality of life can be reduced.

Outpatients' attitudes and understanding regarding living wills.

Objective: To assess outpatients’ attitudes toward and understanding of a standard living will.Design: Survey using a self-administered questionnaire that patients completed after they had read a sample living will.Setting: General medicine clinic of a Department of Veterans Affairs medical center.Patients: Two hundred fourteen patients (85% of those approached) attending a continuity care clinic appointment. Eighty-seven percent were men; mean age was 60 years.Measurements and main results: Patients’ attitudes toward living wills, understanding of the terminology contained in living wills, desire to discuss living wills with their doctors, and desire to prepare a living will.Results: Seventy-two percent of the patients had prior knowledge of living wills, though only 53% had discussed the topic with family members and only 14% with physicians. Half felt that the living will terminology should be simplified, and 55% were unable to identify the correct definition for at least one commonly used term. Desire to prepare a living will was positively associated with better understanding of the sample document and previous knowledge of and exposure to living wills, and was negatively associated with concern about its use and revocability (all p<0.001). Patients who reported poor understanding of the living will were more likely to want to discuss the topic with a physician (p<0.01).Conclusions: In this ambulatory patient population attitudes toward living wills were influenced by knowledge and understanding of these documents. Primary care physicians and institutions should develop patient education strategies that enhance understanding of advance directives.

Self-reported exposures and their association with unexplained illness in a population-based case-control study of Gulf War veterans.

Many factors have been considered as possible causes of the unexplained illness reported by veterans of the Gulf War (GW). In this study, we report an analysis of risk factors and unexplained illness in a population-based sample of GW veterans who underwent clinical evaluation. Multiple risk factors were compared in 241 veterans who met criteria for unexplained illness and 113 healthy controls. Results suggest that GW unexplained illness is most highly associated with combat conditions, heat stress, and having sought medical attention during the GW. When controlling for multiple simultaneous exposures during the GW, interactions around pyridostigmine bromide, insecticides and repellents, and stress were not significant. These results indicate that most unexplained illness in GW veterans cannot be explained by neurotoxic effects of exposures to chemicals that inhibit cholinesterase activity.

U.S. Gulf War Veterans: Service periods in theater, differential exposures, and persistent unexplained illness

Approximately 80,000 of the 697,000 American men and women who were stationed in SW Asia during the Gulf War (GW) report unexplained illness consisting of symptoms of persistent fatigue, cognitive difficulties, such as mild memory loss, diffuse muscle and joint pain, gastrointestinal symptoms, skin lesions, and respiratory problems, among others. Associations between major symptom groups and periods of deployment in the theater of operations have been sought in a population-based, clinical case-control study of GW veterans resident in the north-western region of the United States. No statistically significant differences were evident in the proportion of cases with unexplained fatigue, cognitive/psychological or musculoskeletal symptoms among veterans present in SW Asia in 3 specific time periods: (a) 8/1/1990-12/31/1990 (which includes Desert Shield), (b) the period surrounding Desert Storm (1/1/1991-3/31/1991), and (c) the (post-combat) period immediately following hostilities (4/1/1991-7/31/1991). There was a trend for all 3 case symptoms to be more common among GW veterans who served in the post-combat period. As numbers in these deployment groups were small, and power to detect differences low, the apparent absence of significant differences in the frequency of major symptom groups among these veterans requires confirmation in a larger study. Deployment for discrete periods in SW Asia is a method to separate distinct constellations of environmental factors; these are useful for analyses of associations among symptoms and exposures given the near-total absence of objective data on chemical and other possible exposures in the theater of operations.

Teaching headache management to medicine residents.

Background.—To evaluate the effect of teaching headache management to PG‐1 medicine residents.