When pain in the arm is ‘all in the head’: The management of medically unexplained suffering in primary care

Cases of medically unexplained arm pain pose a dilemma for general practitioners. The absence of observable physical pathology implies a psychosocial problem, but patients often insist that their illness is bio-mechanical. Should the doctor risk invalidating the patient's claims and damaging the doctor – patient relationship, by insisting on a psycho-social explanation, or follow the patient's wishes and prescribe treatments which are likely to be ineffective? Findings from a qualitative study of 14 general practitioners in the South West of England are presented and discussed in the context of the sociology of suffering. The findings indicate a high degree of clinical uncertainty in dealing with non-specific arm pain cases and identify a range of strategies adopted to manage this uncertainty and the problems associated with it. Critics of ‘bio-medicine’ have argued that it focuses narrowly on physical pathology, while neglecting the patient's subjective beliefs and emotional needs. Our findings question this view, suggesting that GPs are often prepared to set aside the rigour of clinical science and the search for physical pathology in order to avoid invalidating the patient's claim that their illness is bio-mechanical rather than psycho-social. While this conforms to cultural expectations of what constitutes an appropriate response to human suffering, it may not be in the patient's best interests.     

Family Intervention with the Traumatically Brain Injured Patient

The occupational therapist plays an integral role in the evaluation and treatment of the traumatically brain injured (TBI) patient. Although the TBI patient's needs are relatively well-defined by the nature of the injury, less well recognized and frequently over- 1ooked is the emotional and psychological trauma experienced by the family of the TBI patient. Depending on the information provided, the family can be an asset or hindrance in the patient's rehabilitation. By working with the TBI patient's family, the occupational therapist can guide the family into a more cohesive force that will assist the patient throughout the rehabilitative process. This article provides suggestions to evaluate and manage concerns and fears raised by the families of TBI patients. It rovides an organizational guideline for educating the family about BI and incorporating them in the rehabilitation of the TBI patient.     

Understanding Others: A Course to Learn Interactive Clinical Reasoning

SUMMARY

Teaching future practitioners to use clinical reasoning processes is necessary for entry-level practice. While there are numerous articles addressing some aspects of clinical reasoning, none describe a course solely focused on understanding another person's perspective–interactive clinical reasoning. The article describes an Interactive Clinical Reasoning course for entry-level graduate students–one of four seminars on clinical reasoning embedded in a curriculum that simultaneously uses an infusion model to increase cultural awareness and sensitivity. The underlying philosophy of the course includes using interpersonal intelligence (Gardner, 1985) to “treat a patient's illness experience” (Mattingly, 1992, p. 4). Clients are the experts of their own experience with illness or disability, and students must pay as much attention to their questions and their own reactions as to their interviewee's responses. Readings, videotapes, assignments, and class exercises designed to increase students' interviewing skills and their ability to understand each client's perspective are described.     

A storybook method for exploring young children's views of illness causality in relation to the familial context

In this paper we describe a method for exploring young children's views of illness causality in social context. Studies of children's conceptualisation of illness have predominantly focused on the nature of children's knowledge rather than locating that knowledge within socio-cultural contexts. Adopting a socio-constructivist perspective we sought to identify the ways in which young children's illness causality concepts are embedded in the socio-cultural context of the family. Interviews were undertaken with four-year-old children, their parents/guardians, sibling/s aged five to nine years and two other family members. To aid the elicitation of young children's narrative accounts of illness causality, children were invited to construct a storybook about ‘getting sick’ utilising art materials and photographs of children experiencing illness. In this paper we describe this method, discuss its utility in eliciting illness narratives from pre-school children and provide suggestions for the use of this method in future research.     

The functions of medical care.

Medical care has several important functions other than restoring or maintaining health. These other functions are assessment and certification of health status, prognostication, segregation of the ill to limit communication of illness, and helping to cope with the problems of illness--the caring function. Medical care serving these "paracurative" functions may legitimately be given indepedently, without associated curing or preventive intent of the provider of care. Although such services do not result in benefits to health, such as extension of life or reduction of disability, they do have other valued outcomes, outcomes not measurable as a gain in personal health status. For example, caring activities may result in satisfaction, comfort, or desirable affective states, even while the patient''s health status deteriorates during an incurable illness. The physician''s approach to patients, the economist''s analysis of the benefits of health services, the planner''s decisions about health programs, the evaluator''s judgments about the quality of care, or the patient''s expectations about treatment are strongly influenced by his assumptions about the purpose of medical care or the proper outcome of the process. When the health worker assumes that the only useful outcome is health, he may consider the paracurative services to be ineffective, inefficient, or undesirable. In contrast, when he recognizes and understands the paracurative functions of medical care, he may better perform his function in the medical care system.     

Air Pollution and Disease

Although air pollution does not produce a specific illness from which people die, it aggravates many preexisting cardiac and respiratory conditions, particularly (among the latter) asthma, emphysema, and chronic bronchitis. It may also add to the hazards of anesthesia. Guidelines are offered for evaluating the contribution air pollutants may make to a patient's illness, especially when he is already at risk.     

Genetic testing: Do healthcare professionals have a duty to tell a patient's family members that they may be at risk?

The author describes the healthcare professional's dilemma of keeping a patient's genetic information confidential. Provided are case law, commentary and policy developments addressing confidentiality of patient information as weighed against third parties' needs to know genetic information regarding their family members.     

Family Predictors of Psychosocial Outcomes Among Hong Kong Chinese Cancer Patients in Palliative Care: Living and Dying with the “Support Paradox”

A good death is universally desired. For Chinese patients, the family is believed to play a key role in making this possible. This study aims at exploring the relationship of family-related factors and psychosocial outcomes among Hong Kong Chinese cancer patients in palliative care. Clinical data mining was adopted as the research method. Nurses collected data from clinical interviews with incoming palliative care patients. A total of 935 patients from three years of deceased patient records was included. Stepwise regression analysis demonstrated that “caregivers' support and acceptance” predicted fewer psychosocial symptoms of patients, whereas “depressed family response to patient's illness” and “family anxiety” predicted a greater number of psychosocial symptoms of patients upon their admission to palliative care. The findings suggested two possible pathways toward enhancing the psychosocial experience of dying patients, that is, the “family support pathway” and the “familial-altruistic pathway.” Further reflections on the findings may suggest that these patients may be situated in a “support paradox,” in which they desire family support but also worry about the burden that support places on family members. Implications for practice were discussed in the cultural context.     

How do patients and health professionals perceive the role of family members in the decision-making process regarding the choice of a dialysis method? A qualitative study

BackgroundTherapeutic decisions often seem to be the product of interaction between health professionals and patients alone. However, some realities make it essential to consider family members when examining care of patients, especially in the construction of therapeutic choices. Implementation of measures such as therapeutic patient education to make the patient an actor in his own healthcare, and the impact of disease on the patient's social and professional activities mean there is an important place for family members in a patient's care pathway. This study aims to examine the role of family members and the family environment in decision-making on treatment for patients with chronic kidney disease. It also analyzes how they contribute to the construction of patients’ choices on dialysis methods through their involvement in a therapeutic patient education program.MethodsThis study involved thirty-six semi-structured interviews: sixteen with patients and twenty with health professionals. Therapeutic patient education sessions, interactions and information exchanges between patients and health professionals, as well as participant behaviours, were also observed. Analysis was thematic.ResultsResults indicate that the factors influencing the patient's choice of dialysis methods include the family environment as the place where the disease is experienced, the need to maintain family ties, the advice provided by family members and their active participation in therapeutic patient education sessions and partnership between family members and health professionals in the decision-making process.ConclusionThis study highlights the reality of decision-making processes that can start from a non-hospital setting. Furthermore, it argues for greater consideration of the needs, values, and preferences of family members in mechanisms designed to promote patient participation in therapeutic decisions.     

Good physicians from the perspective of their patients

Background

It is not currently known what is the patient's viewpoint of a "good" physician. We set out to define patient's priorities regarding different physician's attributes in 3 domains important in medical care.

Methods

Patients hospitalized or attending clinics at a large teaching hospital selected the 4 attributes that they considered most important out of 21 listed arbitrarily in a questionnaire. The questionnaire included 7 items each in the domains of patient autonomy, professional expertise and humanism.

Results

Participating patients (n = 445, mean age 57.5 ± 16 years) selected professional expertise (50%), physician's patience and attentiveness (38% and 30%, respectively), and informing the patient, representing the patient's interests, being truthful and respecting patient's preferences (25–36% each) as the most essential attributes. Patient's selections were not significantly influenced by different demographic or clinical background. Selections of attributes in the domain of patient's autonomy were significantly more frequent and this was the preferred domain for 31% and as important as another domain for 16% - significantly more than the domain of professional expertise (P = 0.008), and much more than the domain of humanism and support (P < 0.0005).

Conclusions

Patients studied want their physicians to be highly professional and expert clinicians and show humaneness and support, but their first priority is for the physician to respect their autonomy.     

Parenting With Chronic Cancer: A Relational Perspective

Living with chronic cancer poses unique challenges for parents caring for minor children. The demands of the illness such as pain, fatigue, and loss of mobility, as well as caregiver responsibilities, can conflict with the patient's and partner's idea of what it means to parent. This article examines the ways in which chronic cancer impacts the parental role using Attachment as a theoretical framework. Case examples and implications for clinical practice in both health care and mental health settings are provided.     

A Home Care Program for Children with Chronic Illness

Pediatric Home Care (PHC) of Albert Einstem College of Medicine was designed as a special ambulatory care unit for children who are seriously or chronically ill and whose needs were not being met successfully through conventional programing Services include monitoring the patient's care, delivering direct services in the home, clinic, and hospital, teaching therapeutic programs to the family and patient, coordinating services, patient advocacy, health education, and supportive counseling Each patient has a core team consisting of a generalist pediatrician, a PNP, and the patient's family Visits are provided in the patient's home as needed, as well as in the traditional locations of the clinic, the inpatient units, and the PHC office The program accepts patients with serious medical problems and who face any of a series of other difficulties, including especially complex management problems that cannot be handled well in the customary outpatient settings, unstable family settings, or extended hospitalizations Because it is not restricted to any single type of disease, the PHC provides a model that is applicable in a wide range of medical and community settings Results of a program evaluation show that PHC is an effective intervention that has positive mental health outcomes and improves satisfaction with care.     

Behavioural differences between twin and non-twin female sibling pairs discordant for anorexia nervosa

Despite the voluminous literature on anorexia nervosa, its aetiology remains an issue of speculation and debate. Family influences have long been considered important, but genetic factors only recently have attracted interest. We surveyed a consecutive sample of anorexia nervosa patients referred to our service and identified 11 patients who were members of a same-sex twin pair. To our surprise, in no instance was there evidence that the co-twin was concordant for the illness. This finding contrasts with other reports in the literature, and it aroused our interest in the effects of being a twin on susceptibility to the illness. The aim of the present study was to determine whether there were any significant differences in premorbid factors and in symptoms following the development of the illness in 11 twin anorexia nervosa females who were compared with 11 non-twin anorexic patients. The development of each patient was also contrasted with that of a sister. The development of each patient was elicited from the patient's mother by means of an interview schedule that contained questions relating to parental background, birth history, infancy, and adolescent development stages, as well as daughter's attitudes towards school, food, appearance, and weight-reducing behaviours, including eating, exercise, and sport. The findings suggest that there may be differences in clinical pictures presented by twin and non-twin anorexia nervosa patients that could influence response to treatment and outcome.     

Reflexiones bioéticas sobre el cuidado prematuro desencadenado por el diagnóstico precoz de la enfermedad de Alzheimer

Early diagnosis of Alzheimer disease raises important bioethical issues. In the interval between early disease detection and symptom onset, there is a time in which the patient's autonomy, privacy, and dignity may be undermined by certain healthcare measures or by family care and support. These measures may eventually turn patients into an object of care, preventing them from accepting the disease, developing an identity, and rearranging their living spaces. Every effort should be made to ensure that care does not become compassionate harassment or an invasive act, annulling the patient's autonomy, identity, and self-determination.     

SOCIAL AND EMOTIONAL NEEDS OF GERIATRIC SURGERY PATIENTS

This review of the social and emotional needs of 90 geriatric surgery patients identifies geriatric surgery as precipitant to crisis in social experience. The patient's personal growth and capacity to mobilize synergy within his/her social systems can be stimulated through the social work relationship. The role of the physician in facilitating that relationship to help patient and family handle stress related to medical crises and appropriate discharge planning emerges as crucial both in timing and understanding. With the exception of patients in a late phase of terminal illness and those confronted with exceptionally complicated medical-social realities, most of these patients were able, with adequate social work help and community support, to function outside an institution. Their movement through various levels of care in the health system required sustained social work help adapted to individual need.     

Sexual changes in a case of gastric stapling in adolescence

This is the case of an adolescent female who developed a moderately severe depressive illness eighteen months after a gastric stapling procedure for morbid obesity. The weight loss following surgery was associated with an emergence of sexual awareness and interest, culminating in the patient's infatuation with a medical practitioner. The importance of an assessment of psychosexual development is discussed in relation to this procedure.     

Somatization in response to undiagnosed obsessive compulsive disorder in a family

Background

Somatization is a common problem in primary care and often presents puzzling problems for the family physician. A family or contextual approach is often useful in investigating and treating refractory symptoms.

Case presentation

A 63 year-old patient presented to his family physician with recurrent episodes of syncope, weakness and various other somatic symptoms. Lengthy clinical investigations found no organic pathological findings but a brief family assessment by the family physician revealed that the patient's wife was the "hidden" patient. Successful treatment of the patient's wife led to full recovery for both.

Conclusions

Exploration and treatment of the family context may often hold the key to the solution of difficult problems in somatizing patients.

     

Measuring Satisfaction with Social Work Services

For various reasons, the role of the medical social worker is often unclear to persons seeking medical treatment. Allied health professionals, such as nursing staff, tend to have a better understanding of the medical social worker's role and of whether services are being provided to best meet each patient's needs. We aimed to illustrate the abilities of nursing staff to provide patient satisfaction feedback to medical social workers in such areas as responsiveness to patient requests and the satisfaction of patients and their family members with the social services provided. Use of this satisfaction measurement technique will hopefully resolve any confusion that patients, and others not familiar with the role of the medical social worker, may have. This method provides accurate measurement of patients' evaluation of medical social work services.     

Nurse Overestimation of Patients' Health Literacy

Patient education and effective communication are core elements of the nursing profession; therefore, awareness of a patient's health literacy is integral to patient care, safety, education, and counseling. Several past studies have suggested that health care providers overestimate their patient's health literacy. In this study, the authors compare inpatient nurses' estimate of their patient's health literacy to the patient's health literacy using Newest Vital Sign as the health literacy measurement. A total of 65 patients and 30 nurses were enrolled in this trial. The results demonstrate that nurses incorrectly identify patients with low health literacy. In addition, overestimates outnumber underestimates 6 to 1. The results reinforce previous evidence that health care providers overestimate a patient's health literacy. The overestimation of a patient's health literacy by nursing personnel may contribute to the widespread problem of poor health outcomes and hospital readmission rates.     

The impact of disease on family members: a critical aspect of medical care

Most existing health-related quality of life research concerns the impact of disease on patients. However, in several medical specialties including dermatology, oncology, and physical and mental disability, studies have been carried out investigating the impact of disease on the lives of families of patients. The aim of this paper is to review the literature which relates to the impact of disease on family members of patients. The OVIDSP Medline was selected as the primary database, Searches were limited to sources published in English. 158 papers were identified for review. The definition of “family” varied across the literature, and a broad definition was accepted in this review. This review shows that a wide variety of aspects of family members’ lives can be affected, including emotional, financial, family relationships, education and work, leisure time, and social activities. Many of these themes are linked to one another, with themes including financial impact and social impact being linked to emotional impact. Some positive aspects were also identified from the literature, including family relationships growing stronger. Several instruments exist to measure the impact of illness on the family, and most are disease or specialty- specific. The impact of disease on families of patients is often unrecognised and underestimated. Taking into account the quality of life of families as well as patients can offer the clinician a unique insight into issues such as family relationships and the effect of treatment decisions on the patient''s close social group of partner and family.