Stephen D. Nightingale

Sympathy, empathy, and physician resource utilization.

Objective:To test the hypothesis that physicians preferring a sympathetic over an empathetic response to a hypothetical patient’s misfortune will utilize more health care resources in the care of their patients.Design:Physicians were asked to select either the sympathetic response or the empathetic response to a hypothetical patient’s misfortune (death of a spouse) and to state their preferences for intubation of a hypothetical end-stage lung-disease patient. For each physician, hospital records were retrospectively reviewed to assess the mean number of laboratory tests ordered per clinic patient and the mean duration of cardiopulmonary resuscitations he or she performed before declaring his or her efforts unsuccessful.Setting:General medicine clinic at a large urban hospital.Participants:101 physicians above the postgraduate year-1 level who attended the general medicine clinic.Measurements and main results:As hypothesized, physicians selecting the sympathetic option (n=58) had a greater mean preference for intubation (p<0.02), ordered more laboratory tests per patient in clinic (p<0.03), and performed cardiopulmonary resuscitation for longer periods of time before declaring their efforts unsuccessful (p<0.06) than did physicians selecting the empathetic option (n=38).Conclusions:These data suggest that the constructs of sympathy and empathy reflect psychological aspects of physicians that have a measurable influence on their practice behaviors.

Primary prophylaxis with fluconazole against systemic fungal infections in Hiv-positive patients

ObjectiveTo investigate the efficacy of fluconazole prophylaxis against systemic fungal infections in HIV-positive patients. DesignOpen label treatment compared with historical controls. SettingPatients were seen at the Parkland Memorial Hospital HIV Clinic, Dallas, Texas, USA between 1 March 1990 and 28 February 1991. Patients, participantsThree hundred and thirty-seven historical controls were followed for 157 patient-years, and 329 fluconazole-treated patients for 145 patient-years. InterventionsFluconazole (100 mg daily) was administered to all patients with CD4 lymphocyte counts < 68 × 106/l seen at our HIV clinic after 1 March 1990. Main outcome measuresLysis-centrifugation blood cultures were recorded monthly for all patients during both study periods. ResultsTwenty infections (16 cryptococcosis, four histoplasmosis) occurred in 337 historical reference control patients (product-limit 1-year incidence, 7.5 × 2.0/year). Four infections (one cryptococcosis, three histoplasmosis) occurred in the treated patient group (product-limit 1-year incidence, 1.8 × 0.9/year). ConclusionsFluconazole warrants further evaluation for prophylaxis against systemic fungal infections in HIV-positive patients.

Prophylaxis with Weekly Versus Daily Fluconazole for Fungal Infections in Patients with AIDS

We compared the efficacy of a 400-mg once-weekly dosage versus a 200-mg daily dosage of fluconazole for the prevention of deep fungal infections in a multicenter, randomized, double-blind trial of 636 human immunodeficiency virus-infected patients to determine if a less intensive fluconazole regimen could prevent these serious but relatively infrequent complications of AIDS. In the intent-to-treat analysis, a deep fungal infection developed in 17 subjects (5.5%) randomly assigned to daily fluconazole treatment and in 24 (7.7%) given weekly fluconazole during 74 weeks of follow-up (risk difference, 2.2%; 95% confidence interval [CI], -1.7% to 6.1%). Thrush occurred twice as frequently in the weekly versus daily fluconazole recipients (hazard ratio, 0.59; 95% CI, 0.40-0.89), and in a subset of patients evaluated, fluconazole resistance was infrequent. Fluconazole administered once weekly is effective in reducing deep fungal infections in patients with AIDS, but this dosage is less effective than the 200-mg-daily dosage in preventing thrush.

Risk Preference and Laboratory Use

One hundred thirty-seven physicians were asked to choose between a certain loss of five years of life expectancy and a 50/50 gamble of losing either ten years or zero years of life expectancy. These choices were presented as hypothetical options for a patient with cancer. The 46 who chose the certain loss ordered 23% fewer laboratory tests/patient visit in our General Medicine Clinic over an eight-week period than those who chose the gamble (p <0.05). This risk preference was further stratified by sequentially offering five, four, three, two, and one years of certain loss against the same 50/50 gamble of ten or zero years of loss; greater preference for the gamble correlated with greater laboratory use (p <0.002). To exclude physician knowledge or case mix as a cause of this result, this risk preference was correlated with total score, and with the cost of tests ordered in patient management problems, of 49 physicians on the American Board of Internal Medicine Certifying Examination. Cost of tests ordered was 23% less for the 17 who chose the certain loss (p <0.001 ); total score did not vary with risk preferences. There was no association between risk preference in the face of gain and laboratory use, and none between an individuals risk preferences in the face of gain and in the face of loss. The cognitive processes that determine risk preference in the face of loss, whatever they may be, appear to have a substantial influence on physician test-ordering behavior.

Risk preference and laboratory test selection

The risk preferences in situations of potential gain, and of potential loss, expressed by 67 physicians were correlated with the numbers of laboratory tests they selected after review of identical copies of two outpatient charts. Physicians who chose a 50/50 gamble of losing ten or no years of life expectancy over an equivalent certain loss of five years selected twice as many tests as those who chose the loss (p<0.025). Risk preferences may provide some insight into why some physicians order more laboratory tests than do others.