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1.
Context  Medical errors are associated with feelings of distress in physicians, but little is known about the magnitude and direction of these associations. Objective  To assess the frequency of self-perceived medical errors among resident physicians and to determine the association of self-perceived medical errors with resident quality of life, burnout, depression, and empathy using validated metrics. Design, Setting, and Participants  Prospective longitudinal cohort study of categorical and preliminary internal medicine residents at Mayo Clinic Rochester. Data were provided by 184 (84%) of 219 eligible residents. Participants began training in the 2003-2004, 2004-2005, and 2005-2006 academic years and completed surveys quarterly through May 2006. Surveys included self-assessment of medical errors and linear analog scale assessment of quality of life every 3 months, and the Maslach Burnout Inventory (depersonalization, emotional exhaustion, and personal accomplishment), Interpersonal Reactivity Index, and a validated depression screening tool every 6 months. Main Outcome Measures  Frequency of self-perceived medical errors was recorded. Associations of an error with quality of life, burnout, empathy, and symptoms of depression were determined using generalized estimating equations for repeated measures. Results  Thirty-four percent of participants reported making at least 1 major medical error during the study period. Making a medical error in the previous 3 months was reported by a mean of 14.7% of participants at each quarter. Self-perceived medical errors were associated with a subsequent decrease in quality of life (P = .02) and worsened measures in all domains of burnout (P = .002 for each). Self-perceived errors were associated with an odds ratio of screening positive for depression at the subsequent time point of 3.29 (95% confidence interval, 1.90-5.64). In addition, increased burnout in all domains and reduced empathy were associated with increased odds of self-perceived error in the following 3 months (P=.001, P<.001, and P=.02 for depersonalization, emotional exhaustion, and lower personal accomplishment, respectively; P=.02 and P=.01 for emotive and cognitive empathy, respectively). Conclusions  Self-perceived medical errors are common among internal medicine residents and are associated with substantial subsequent personal distress. Personal distress and decreased empathy are also associated with increased odds of future self-perceived errors, suggesting that perceived errors and distress may be related in a reciprocal cycle.   相似文献   

2.
The Relationship Between Method of Physician Payment and Patient Trust   总被引:31,自引:1,他引:30  
Context.— Trust is the cornerstone of the patient-physician relationship. Payment methods that place physicians at financial risk have raised concerns about patients' trust in physicians to act in patients' best interests. Objective.— To evaluate the extent to which methods of physician payment are related to patient trust. Design.— Cross-sectional telephone interview survey done between January and June 1997. Setting.— Health plans of a large national insurer in Atlanta, Ga, the Baltimore, Md–Washington, DC, area, and Orlando, Fla. Participants.— A total of 2086 adult managed care and indemnity patients. Main Outcome Measure.— A 10-item scale (=.94) assessing patients' trust in physicians. Results.— More fee-for-service (FFS) indemnity patients (94%) completely or mostly trust their physicians to "put their health and well-being above keeping down the health plan's costs" than salary (77%), capitated (83%), or FFS managed care patients (85%) (P<.001 for pairwise comparisons). In multivariate analyses that adjusted for potentially confounding factors, FFS indemnity patients also had higher scores on the 10-item trust scale than salary (P<.001), capitated (P<.001), or FFS managed care patients (P<.01). The effects of payment method on patient trust were reduced when a measure based on patients' reports about physician behavior (eg, Does your physician take enough time to answer your questions?) was included in the regression analyses, but the differences remained statistically significant, except for the comparison between FFS managed care and FFS indemnity patients (P=.08). Patients' perceptions of how their physicians were paid were not independently associated with trust, but the 37.7% who said they did not know how their physicians were paid had higher levels of trust than other patients (P<.01). A total of 30.2% of patients were incorrect about their physicians' method of payment. Conclusions.— Most patients trusted their physicians, but FFS indemnity patients have higher levels of trust than salary, capitated, or FFS managed care patients. Patients' reports of physician behavior accounted for part of the variation in patients' trust in physicians who are paid differently. The impact of payment methods on patient trust may be mediated partly by physician behavior.   相似文献   

3.
National Patterns in the Treatment of Smokers by Physicians   总被引:20,自引:1,他引:19  
Context.— Routine treatment of smokers by physicians is a national health objective for the year 2000, a quality measure for health care plans, and the subject of evidence-based clinical guidelines. There are few national data on how physicians' practices compare with these standards. Objective.— To assess recent trends in the treatment of smokers by US physicians in ambulatory care and to determine whether physicians' practices meet current standards. Design.— Analysis of 1991-1995 data from the National Ambulatory Medical Care Survey, an annual survey of a random sample of US office-based physicians. Setting.— Physicians' offices. Patients.— A total of 3254 physicians recorded data on 145716 adult patient visits. Main Outcome Measures.— The proportion of visits at which physicians (1) identified a patient's smoking status, (2) counseled a smoker to quit, and (3) used nicotine replacement therapy. Results.— Smoking counseling by physicians increased from 16% of smokers' visits in 1991 to 29% in 1993 (P<.001) and then decreased to 21% of smokers' visits in 1995 (P<.001). Nicotine replacement therapy use followed a similar pattern, increasing from 0.4% of smokers' visits in 1991 to 2.2% in 1993 (P<.001) and decreasing to 1.3% of smokers' visits in 1995 (P=.007). Physicians identified patients' smoking status at 67% of all visits in 1991; this proportion did not increase over time. Primary care physicians were more likely to provide treatment to smokers than were specialists. All physicians were more likely to treat patients with smoking-related diagnoses. Conclusions.— US physicians' treatment of smokers improved little in the first half of the 1990s, although a transient peak in counseling and nicotine replacement use occurred in 1993 after the introduction of the nicotine patch. Physicians' practices fell far short of national health objectives and practice guidelines. In particular, patient visits for diagnoses not related to smoking represent important missed opportunities for intervention.   相似文献   

4.
Physicians Disciplined for Sex-Related Offenses   总被引:3,自引:0,他引:3  
Dehlendorf  Christine E.; Wolfe  Sidney M. 《JAMA》1998,279(23):1883-1888
Context.— Physicians who abuse their patients sexually cause immense harm, and, therefore, the discipline of physicians who commit any sex-related offenses is an important public health issue that should be examined. Objectives.— To determine the frequency and severity of discipline against physicians who commit sex-related offenses and to describe the characteristics of these physicians. Design and Setting.— Analysis of sex-related orders from a national database of disciplinary orders taken by state medical boards and federal agencies. Subjects.— A total of 761 physicians disciplined for sex-related offenses from 1981 through 1996. Main Outcome Measures.— Rate and severity of discipline over time for sex-related offenses and specialty, age, and board certification status of disciplined physicians. Results.— The number of physicians disciplined per year for sex-related offenses increased from 42 in 1989 to 147 in 1996, and the proportion of all disciplinary orders that were sex related increased from 2.1% in 1989 to 4.4% in 1996 (P<.001 for trend). Discipline for sex-related offenses was significantly more severe (P<.001) than for non–sex-related offenses, with 71.9% of sex-related orders involving revocation, surrender, or suspension of medical license. Of 761 physicians disciplined, the offenses committed by 567 (75%) involved patients, including sexual intercourse, rape, sexual molestation, and sexual favors for drugs. As of March 1997, 216 physicians (39.9%) disciplined for sex-related offenses between 1981 and 1994 were licensed to practice. Compared with all physicians, physicians disciplined for sex-related offenses were more likely to practice in the specialties of psychiatry, child psychiatry, obstetrics and gynecology, and family and general practice (all P<.001) than in other specialties and were older than the national physician population, but were no different in terms of board certification status. Conclusions.— Discipline against physicians for sex-related offenses is increasing over time and is relatively severe, although few physicians are disciplined for sexual offenses each year. In addition, a substantial proportion of physicians disciplined for these offenses are allowed to either continue to practice or return to practice.   相似文献   

5.
Context.— Cryptosporidium parvum infection, a common cause of diarrhea in persons infected with the human immunodeficiency virus (HIV), is difficult to treat or prevent. Objective.— To evaluate relative rates of cryptosporidiosis in HIV-infected patients who were either receiving or not receiving chemoprophylaxis or treatment for Mycobacterium avium complex. Design.— Analysis of prospectively collected data from HIV-infected patients' visits to their physicians since 1992. Setting.— Ten (8 private, 2 publicly funded) HIV clinics in 9 US cities. Patients.— A total of 1019 HIV-infected patients with CD4+ cell counts less than 0.075x109/L. Main Outcome Measures.— Incidence of clinical cryptosporidiosis during treatment with clarithromycin, rifabutin, and azithromycin. Results.— Five of the 312 patients reportedly taking clarithromycin developed cryptosporidiosis vs 30 of the 707 patients not taking clarithromycin (relative hazard [RH], 0.25 [95% confidence interval (CI), 0.10-0.67]; P =.004).Two of the 214 patients taking rifabutin developed cryptosporidiosis vs 33 of the 805 not taking rifabutin (RH, 0.15 [95% CI, 0.04-0.62]; P=.01). Prophylactic efficacy of either drug was 75% or greater. No protective effect was seen in the 54 patients reportedly taking azithromycin (RH, 1.48 [95% CI, 0.44-5.04]; P=.46). Conclusions.— Clarithromycin and rifabutin were highly protective against development of cryptosporidiosis in immune-suppressed HIV-infected persons in this analysis; further study is warranted.   相似文献   

6.
Kuo  David; Gifford  David R.; Stein  Michael D. 《JAMA》1998,280(10):905-909
Context.— Informal (curbside) consultations are an integral part of medical culture and may be of great value to patients and primary care physicians. However, little is known about physicians' behavior or attitudes toward curbside consultation. Objective.— To describe and compare curbside consultation practices and attitudes among primary care physicians and medical subspecialists. Design.— Survey mailed in June 1997. Participants.— Of 286 primary care physicians and 252 subspecialists practicing in Rhode Island, 213 primary care physicians and 200 subspecialists responded (response rate, 76.8%). Main Outcome Measures.— Self-reported practices of, reasons for, and attitudes about curbside consultation. Results.— Of primary care physicians, 70.4% (150/213) and 87.5% (175/200) of subspecialists reported participating in at least 1 curbside consultation during the previous week. In the previous week, primary care physicians obtained 3.2 curbside consultations, whereas subspecialists received 3.6 requests for curbside consultations. Subspecialties most frequently involved in curbside consultations were cardiology, gastroenterology, and infectious diseases; subspecialties that were requested to provide curbside consultations more often than they were formally consulted were endocrinology, infectious diseases, and rheumatology. Curbside consultations were most often used to select appropriate diagnostic tests and treatment plans and to determine the need for formal consultation. Subspecialists perceived more often than primary care physicians that information communicated in curbside consultations was insufficient (80.2% vs 49.8%; P<.001) and that important clinical detail was not described (77.6% vs 43.5%; P <.001). More subspecialists than primary care physicians felt that curbside consultations were essential for maintaining good relationships with other physicians (77.2% vs 38.6%; P <.001). Conclusions.— Curbside consultation serves important functions in the practice of medicine. Despite the widespread use of curbside consultation, disagreement exists between primary care physicians and subspecialists as to the role of curbside consultation and the quality of the information exchanged.   相似文献   

7.
Testa  Marcia A.; Simonson  Donald C. 《JAMA》1998,280(17):1490-1496
Context.— Although the long-term health benefits of good glycemic control in patients with diabetes are well documented, shorter-term quality of life (QOL) and economic savings generally have been reported to be minimal or absent. Objective.— To examine short-term outcomes of glycemic control in type 2 diabetes mellitus (DM). Design.— Double-blind, randomized, placebo-controlled, parallel trial. Setting.— Sixty-two sites in the United States. Participants.— A total of 569 male and female volunteers with type 2 DM. Intervention.— After a 3-week, single-blind placebo-washout period, participants were randomized to diet and titration with either 5 to 20 mg of glipizide gastrointestinal therapeutic system (GITS) (n=377) or placebo (n=192) for 12 weeks. Main Outcome Measures.— Change from baseline in glucose and hemoglobin A1c (HbA1c) levels and symptom distress, QOL, and health economic indicators by questionnaires and diaries. Results.— After 12 weeks, mean (±SE) HbA1c and fasting blood glucose levels decreased with active therapy (glipizide GITS) vs placebo (7.5%±0.1% vs 9.3%±0.1% and 7.0±0.1 mmol/L [126±2 mg/dL] vs 9.3±0.2 mmol/L [168±4 mg/dL], respectively; P<.001). Quality-of-life treatment differences (SD units) for symptom distress (+0.59; P<.001), general perceived health (+0.36; P=.004), cognitive functioning (+0.34; P=.005), and the overall visual analog scale (VAS) (+0.24; P=.04) were significantly more favorable for active therapy. Subscales of acuity (+0.38; P=.002), VAS emotional health (+0.35; P =.003), general health (+0.27; P =.01), sleep (+0.26; P =.04), depression (+0.25; P =.05), disorientation and detachment (+0.23; P =.05), and vitality (+0.22; P =.04) were most affected. Favorable health economic outcomes for glipizide GITS included higher retained employment (97% vs 85%; P<.001), greater productive capacity (99% vs 87%; P<.001), less absenteeism (losses=$24 vs $115 per worker per month; P <.001), fewer bed-days (losses=$1539 vs $1843 per 1000 person-days; P=.05), and fewer restricted-activity days (losses=$2660 vs $4275 per 1000 person-days; P=.01). Conclusions.— Improved glycemic control of type 2 DM is associated with substantial short-term symptomatic, QOL, and health economic benefits.   相似文献   

8.
Physicians' Experiences and Beliefs Regarding Informal Consultation   总被引:3,自引:0,他引:3  
Context.— Efforts to control medical expenses by emphasizing primary care and limiting specialty care may influence how physicians use informal or "curbside" consultation. Objective.— To understand physicians' use of and beliefs about informal consultation. Design.— Survey mailed in July 1997. Participants.— Of a random sample of Massachusetts general internists, pediatricians, cardiologists, orthopedic surgeons (n=300 each), and infectious disease specialists (n=200) surveyed, 1225 were eligible and 705 (58%) responded. Main Outcome Measures.— Self-reported use of and beliefs about informal consultation. Results.— Generalist physicians requested more informal consultations than specialists (median, 3 vs 1 per week; P <.001) and were asked to provide fewer (2 vs 5 per week; P <.001). In multivariate analyses, physicians in a health maintenance organization, multispecialty group, or single-specialty group requested more informal consultations than those in solo practice (82%, 40%, and 28% more, respectively; all P<.001) and were more often asked to provide them (43%, 63%, and 14% more, respectively; all P<.05). Physicians with at least 30% of their income from capitation requested 38% more and were asked to provide 46% more informal consultations than those with little or no income from capitation (both P<.001). Generalists' overall approval of informal consultation was greater than specialists' (mean 5.9 vs 5.1 on a 7-point Likert scale; P<.001), and approval was strongly associated with beliefs about how informal consultation affects quality of care (P<.001). Conclusions.— Use of informal consultation is common, varies by specialty, practice setting, and capitation, and therefore may increase with current trends toward group practice and managed care. Because overall approval of informal consultation is strongly associated with beliefs about how it affects quality of care, this issue should be carefully considered by physicians who participate in informal consultation.   相似文献   

9.
Bellini LM  Baime M  Shea JA 《JAMA》2002,287(23):3143-3146
Context  Internship is a time of great transition, during which mood disturbances are common. However, variations in mood and empathy levels throughout the internship year have not been investigated. Objective  To examine mood patterns and changes in empathy among internal medicine residents over the course of the internship year. Design  Cohort study of interns involving completion of survey instruments at 4 points: time 1 (June 2000; Profile of Mood States [POMS] and Interpersonal Reactivity Index [IRI]), times 2 and 3 (November 2000 and February 2001; POMS), and time 4 (June 2001; POMS and IRI). Setting  Internal medicine residency program at a university-based medical center. Participants  Sixty-one interns. Main Outcome Measures  Baseline scores of mood states and empathy; trends in mood states and empathy over the internship year. Results  Response rates for time 1 were 98%; for time 2, 72%; for time 3, 79%; and for time 4, 79%. Results of the POMS revealed that physicians starting their internship exhibit less tension, depression, anger, fatigue, and confusion and have more vigor than general adult and college student populations (P<.001 for all). Results of the IRI showed better baseline scores for perspective taking (P<.001) and empathic concern (P = .007) and lower scores for personal distress (P<.001) among interns compared with norms. Five months into internship, however, POMS scores revealed significant increases in the depression-dejection (P<.001), anger-hostility (P<.001), and fatigue-inertia (P<.001) scales, as well as an increase in IRI personal distress level (P<.001). These increases corresponded with decreases in the POMS vigor-activity scores (P<.001) and IRI empathic concern measures (P = .005). Changes persisted throughout the internship period. Conclusions  We found that, in this sample, enthusiasm at the beginning of internship soon gave way to depression, anger, and fatigue. Future research should be aimed at determining whether these changes persist beyond internship.   相似文献   

10.
Context.— Acidic foods such as orange juice have been thought to be unlikely vehicles of foodborne illness. Objective.— To investigate an outbreak of Salmonella enterica serotype Hartford (Salmonella Hartford) infections among persons visiting a theme park in Orlando, Fla, in 1995. Design.— Review of surveillance data, matched case-control study, laboratory investigation, and environmental studies. Setting.— General community. Participants.— The surveillance case definition was Salmonella Hartford or Salmonella serogroup C1 infection in a resident of or a visitor to Orlando in May or June 1995. In the case-control study, case patients were limited to theme park hotel visitors and controls were matched to case patients by age group and hotel check-in date. Main Outcome Measures.— Risk factors for infection and source of implicated food. Results.— Sixty-two case patients from 21 states were identified. Both Salmonella Hartford and Salmonella enterica serotype Gaminara (Salmonella Gaminara) were isolated from stool samples of 1 ill person. Thirty-two case patients and 83 controls were enrolled in the case-control study. Ninety-seven percent of case patients had drunk orange juice in the theme park vs 54% of controls (matched odds ratio, undefined; 95% confidence interval, 5.2 to undefined). The orange juice was unpasteurized and locally produced. Salmonella Gaminara was isolated from 10 of 12 containers of orange juice produced during May and July, indicating ongoing contamination of juice probably because of inadequately sanitized processing equipment. Conclusions.— Unpasteurized orange juice caused an outbreak of salmonellosis in a large Florida theme park. All orange juice was recalled and the processing plant closed. Pasteurization or other equally effective risk-management strategies should be used in the production of all juices.   相似文献   

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