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1.
Debra K. Litzelman MD MA Dr. William M. Tierney MD 《Journal of general internal medicine》1996,11(8):497-499
The objective of this study was to assess reasons for physicians’ noncompliance with computer-generated preventive care reminders.
In an academic general internal medicine practice, a survey of physicians’ reasons for noncompliance found that 55% of reminders
were not complied with. Reasons included “not applicable” in 22.6% (test done elsewhere, patient too ill, no uterus), “next
visit” in 22.5% (physician too busy, patient too ill), and “patient refuses” in 9.9% (test not necessary or too costly, patient
too busy or fears result). We conclude that although noncompliance with reminders is sometimes appropriate, making time for
prevention and patient education may augment preventive care.
Received from the Department of Medicine, Wishard Memorial Hospital, and the Indiana University School of Medicine, the Regenstrief
Institute for Health Care, and the Health Services Research and Development Service, Richard L. Roudebush VA Medical Center,
Indianapolis, Ind.
Supported in part by grants HS07632, HS07763, and HS07719 from the Agency for Health Care Policy and Research (AHCPR). Dr.
Litzelman was supported in part by a Robert Wood Johnson Generalist Physician Faculty Scholar Award (022318).
The opinions expressed herein are solely those of the authors and do not necessarily represent the authors’ institutions,
AHCPR, or the Robert Wood Johnson Foundation. 相似文献
2.
Dr. Lawrence S. Linn PhD Robert H. Brook MD ScD Virginia A. Clark PhD Allyson Ross Davies PhD Arlene Fink PhD Jacqueline Kosecoff PhD Pam Salisbury 《Journal of general internal medicine》1986,1(2):104-108
This paper presents data on the characteristics, work activities, job-related stress, work satisfaction, and career aspirations
of 150 faculty and 595 housestaff physicians who regularly provide continuous primary care in 15 teaching hospital-based group
practices. The faculty were young, board-certified generalists; they had been recruited from local training programs and spent
the majority of their time seeing patients and supervising housestaff. Job satisfaction among faculty and housestaff was generally
high. Dissatisfaction occurred most often with aspects of work over which physicians had little control. Although work-related
stress was common, it was not related to job satisfaction. Compared with housestaff in traditional residency programs, housestaff
enrolled in special Primary Care Training Programs reported significantly greater job satisfaction. For all housestaff, satisfaction
with work in the group practice was consistently associated with decreased interest in subspecialty training.
assisted in preparing this report.
Received from the Department of Medicine and the School of Public Health, UCLA Center for the Health Sciences. Los Angeles.
California.
Supported by Grant #59082 from the Robert Wood Johnson Foundation.
The views expressed herein do not necessarily represent those of the Robert Wood Johnson Foundation. 相似文献
3.
Little is known about the prevalence of focused expertise (special areas of expertise within a clinical field) among physicians,
yet such expertise may influence how care is delivered. We surveyed general internists, pediatricians, cardiologists, infectious
disease specialists, and orthopedic surgeons to describe the prevalence of focused expertise and identify associated physician
and practice characteristics. About one quarter of generalists and three quarters of specialists reported a focused expertise
within their primary specialty. Hospital-based physicians more often reported such expertise, and physicians reimbursed by
capitation less often reported expertise. Learning how focused expertise affects processes and outcomes of care will contribute
to decisions about physician training and staffing of medical groups.
Dr. Keating was the recipient of a National Research Service Award from the Agency for Healthcare Research and Quality, Rockville,
MD, Dr. Ayanian was a Generalist Physician Faculty Scholar of the Robert Wood Johnson Foundation, Princeton, NJ. This study
was supported by the Primary Care Research and Education Fund of Brigham and Women’s Hospital. 相似文献
4.
Objective: Since inordinately long or short lengths of stay at hospice can create problems for patients, providers, and payers, the
author sought to identify predictors of timing of patient referral.
Methods: A retrospective cohort of 405 hospice outpatients was analyzed with Cox regression to evaluate the effect on length of stay
of patient age, gender, race, diagnosis, activity level, mental status, dyspnea, insurance, income, religion, and home support,
and of referring physician specialty.
Results: Median survival time at the hospice was 29 days; 15% of the patients died within seven days and 12% lived longer than 180
days. A one-unit increment in a six-unit activity-level scale was associated with a 19% reduction in the rate of death. Compared
with reference groups, oriented patients and depressed patients had 57% and 35% lower death rates; patients with prostate
cancer and cardiovascular disease had 50% and 58% lower death rates. There was no significant gender, race, religion, insurance,
or income difference among the patient groups.
Conclusions: Inappropriately early or late referral occurs in a substantial minority of patients referred to the hospice under study.
Closer attention to accurate prognostication in different types of terminally ill patients and more timely referral to hospice
might help to optimize the use of this health care resource from both patient and societal perspectives.
Received from the Division of General Internal Medicine, Leonard Davis Institute of Health Economics, Department of Sociology,
University of Pennsylvania, Philadelphia, Pennsylvania.
Supported by the Robert Wood Johnson Foundation Clinical Scholars Program and by the Warren-Whitman-Richardson Fellowship
from Harvard Medical School. Dr. Christakis is the recipient of a NRSA Fellowship from the Agency for Health Care Policy and
Research. Computer facilities were provided by the Department of Sociology, University of Pennsylvania.
The opinions and conclusions herein are the author’s and do not necessarily represent the views of the Robert Wood Johnson
Foundation. 相似文献
5.
Saha S Christakis DA Saint S Whooley MA Simon SR 《Journal of general internal medicine》1999,14(12):745-749
Summary Generalist physicians pursuing fellowship training should develop an early strategic plan to guide them through their fellowship
years. Though each fellow’s plan must be individualized, fellows should get started on independent projects early, decide
how much time to allocate to various activities, strike an individualized balance between course work and independent projects,
and learn how to choose and maintain relationships with mentors. Early decision making with regard to these aspects of fellowship
will allow trainees to maximize their learning, development, and progress toward career goals.
Presented in part as a precourse at the National Meeting of the Society of General Internal Medicine, San Francisco, Calif,
April 1999.
Dr. Whooley is supported by a Research Career Development Award from the Department of Veterans Affairs, Health Services Research
and Development Service. Dr. Saha was a fellow in the Robert Wood Johnson Clinical Scholars Program, University of Washington,
and Health Services Research and Development, VA Puget Sound Health Care System. Drs. Christakis and Saint were fellows in
the Robert Wood Johnson Clinical Scholars Program, University of Washington, Dr. Whooley was a fellow in the Clinical Epidemiology
Fellowship, San Francisco VA Medical Center and University of California, San Francisco, Dr. Simon was a fellow in the Harvard
General Internal Medicine Fellowship and Faculty Development Program, and the Thomas O. Pyle Fellowship in Ambulatory Care
and Prevention, Harvard Medical School and Harvard Pilgrim Health Care. 相似文献
6.
Primary care and receipt of preventive services 总被引:11,自引:0,他引:11
Dr. Andrew B. Bindman MD Kevin Grumbach MD Dennis Osmond PhD Karen Vranizan MA Anita L. Stewart PhD 《Journal of general internal medicine》1996,11(5):269-276
OBJECTIVE: To examine whether health insurance, a regular place of care, and optimal primary care are independently associated with
receiving preventive care services.
DESIGN: A cross-sectional telephone survey.
SETTING: Population based.
PARTICIPANTS: Probability sample of 3,846 English-speaking and Spanish-speaking women between the ages of 18 and 64 in urban California.
INTERVENTIONS: Women were asked about their demographic characteristics, financial status, health insurance status, need for ongoing care,
regular place of care, and receipt of blood pressure screening, clinical breast examinations, mammograms, and Pap smears.
Women who reported a regular place of care were asked about four components of primary care: availability, continuity, comprehensiveness,
and communication.
MEASUREMENTS AND MAIN RESULTS: In multivariate analyses that controlled for differences in demographics, financial status, and need for ongoing care, having
a regular place of care was the most important factor associated with receiving preventive care services (p<.0001). Having health insurance (p<.001) and receiving optimal primary care from the regular place of care (p<.01) further significantly increased the likelihood of receiving preventive care services.
CONCLUSION: A regular source of care is the single most important factor associated with the receipt of preventive services, but optimal
primary care from a regular place increases the likelihood that women will receive preventive care.
Supported by Robert Wood Johnson Foundation grant 22907 and Agency for Health Care Policy Research (AHCPR) grant HSO7373.
Dr. Bindman and Dr. Grumbach are Robert Wood Johnson Foundation Generalist Physician Faculty Scholars. 相似文献
7.
Dr. Wayne C. McCormick MD MPH Thomas S. Inui ScM. MD Richard A. Deyo MD MPH Robert W. Wood MD 《Journal of general internal medicine》1991,6(1):27-34
Objective:As the treatment for HIV infection has improved, AIDS has become a chronic disease, and the demand for long-term care has
increased. The authors studied a cohort of hospitalized persons with AIDS to determine the proportion and characteristics
of AIDS patients who could appropriately be cared for in long-term care facilities with skilled nursing.
Design:Prospective cohort study.
Setting:Medical wards of five Seattle tertiary care hospitals.
Participants:120 consecutive hospitalized persons with AIDS and their primary care physicians, nurses, and social workers.
Measurements and main results:Appropriateness for long-term care was determined by the patients’ physicians, nurses, and social workers. Persons with AIDS
who were appropriate for long-term care constituted 32% of the cohort (38 of 120), accounting for 35% of hospital days (11
of these 38 were discharged to long-term care facilities). Four admission characteristics were independently related to appropriateness:
impaired activities of daily living, diagnosis of central nervous system illness or poor cognition, living alone, and weight
loss. A discriminant function correctly classified over 80% of patients for appropriateness and was developed into a predictive
index for planning patient care (sensitivity =0.74, specificity =0.85).
Conclusions:The authors conclude that one-third of hospitalized persons with AIDS may be appropriate for care in long-term care settings,
accounting for one-third of the days AIDS patients currently spend in hospitals. These patients can be identified early in
hospital stays using a simple predictive index at the bedside.
Presented at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, April 28, 1989.
Supported by the Northwest Health Services Research and Development Field Program (Seattle Veterans Affairs Medical Center)
and the Seattle King County Department of Public Health, AIDS Prevention Project.
The views stated herein are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation
or the Department of Veterans Affairs. 相似文献
8.
Dr. Nicholas A. Christakis MD PhD MPH David A. Asch MD MBA 《Journal of general internal medicine》1995,10(9):491-494
OBJECTIVE: To assess how members of different specialties vary in their decisions about which form of life support to withdraw. The
hypothesis was that each specialty would be more comfortable withdrawing its “own” form of life support relative to other
forms and other specialties.
DESIGN: Mail survey.
SETTING: 24 medical centers.
PARTICIPANTS: 225 specialists in six specialties and 225 comparison physicians randomly matched according to percentage of time devoted
to clinical practice.
MEASUREMENTS: The six specialties were linked with six life-sustaining technologies related to their special expertise: 1) pulmonologists
with mechanical ventilation, 2) nephrologists with hemodialysis, 3) gastroenterologists with tube feedings, 4) hematologists
with blood products, 5) cardiologists with intravenous vasopressors, and 6) infectious disease specialists with antibiotics.
The subjects ranked different forms of life support in the order in which they would prefer to withdraw them. They also expressed
their preferences in response to hypothetical clinical vignettes.
RESULTS: In five of the six specialties, the specialists had a relative preference for withdrawing their “own” form of life support,
compared with the preferences of the comparison physicians. Overall, the physicians tended to prefer withdrawing a form of
life support closely linked with their own specialty.
CONCLUSIONS: Just as some specialist physicians tend to reach for different technologies first in treating patients, they also tend to
reach for different technologies first when ceasing treatment. Specialists’ preferences for different ways to withdraw life
support not only may reflect a special understanding of the limits of certain technologies, but also may reveal how ingrained
are physicians’ patterns of practice.
Supported by the John A. Hartford Foundation, by the Robert Wood Johnson Foundation, and by a Biomedical Research Support
Grant from the National Institutes of Health (DAA and NAC). Dr. Christakis was the recipient of a NRSA Fellowship from the
Agency for Health Care Policy and Research. Dr. Asch was the recipient of a Health Services Research Career Development Award
from the Department of Veterans Affairs.
The opinions and conclusions are those of the authors and do not necessarily represent those of the funding agencies. This
work was conducted at the University of Pennsylvania. 相似文献
9.
Dr. Michael D. Stein MD John Piette MS Vincent Mor PhD Tom J. Wachtel MD John Fleishman PhD Kenneth H. Mayer MD Charles C. J. Carpenter MD 《Journal of general internal medicine》1991,6(1):35-40
Object:To evaluate socioeconomic factors that determine whether symptomatic HIV-infected persons are offered zidovudine (AZT).
Design:Cross-sectional survey conducted as part of the Robert Wood Johnson Foundation’s AIDS Health Services Program.
Setting:Public hospital clinics and community-based AIDS organizations in nine American cities.
Patients:880 HIV-seropositive outpatients interviewed between October 1988 and May 1989.
Main results:Males were more likely to have been offered AZT than were females (adjusted odds ratio 2.99; 95% confidence interval 1.67
to 5.36), those with insurance were more likely to have been offered AZT than were those without (adjusted odds ratio 2.00;
95% confidence interval 1.25 to 3.21), and whites more likely to have been offered AZT than were non-whites (adjusted odds
ratio 1.73; 95% confidence interval 1.11 to 2.69). Intravenous drug users were less likely to have been offered AZT than were
non-drug users (adjusted odds ratio 0.44; 95% confidence interval 0.28 to 0.69). Persons who had had an episode of Pneumocystis cariniipneumonia were more likely to have been offered AZT than were persons who had AIDS and had not had Pneumocystis cariniipneumonia (adjusted odds ratio 2.95; 95% confidence interval 1.71 to 5.11).
Conclusion:The authors conclude that traditionally dis-advantaged groups have less access to AZT, the only antiretroviral agent demonstrated
to increase survival of patients who have symptomatic HIV infection.
Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, May 2–4, 1990.
Supported in part by a grant from the Robert Wood Johnson Foundation (12044). 相似文献
10.
Etzioni DA Yano EM Rubenstein LV Lee ML Ko CY Brook RH Parkerton PH Asch SM 《Diseases of the colon and rectum》2006,49(7):1002-1010
Purpose As evidence mounts for effectiveness, an increasing proportion of the United States population undergoes colorectal cancer
screening. However, relatively little is known about rates of follow-up after abnormal results from initial screening tests.
This study examines patterns of colorectal cancer screening and follow-up within the nation's largest integrated health care
system: the Veterans Health Administration.
Methods We obtained information about patients who received colorectal cancer screening in the Veterans Health Administration from
an existing quality improvement program and from the Veterans Health Administration's electronic medical record. Linking these
data, we analyzed receipt of screening and follow-up testing after a positive fecal occult blood test.
Results A total of 39,870 patients met criteria for colorectal cancer screening; of these 61 percent were screened. Screening was
more likely in patients aged 70 to 80 years than in those younger or older. Female gender (relative risk, 0.92; 95 percent
confidence interval, 0.9–0.95), Black race (relative risk, 0.92; 95 percent confidence interval, 0.89–0.96), lower income,
and infrequent primary care visits were associated with lower likelihood of screening. Of those patients with a positive fecal
occult blood test (n = 313), 59 percent received a follow-up barium enema or colonoscopy. Patient-level factors did not predict
receipt of a follow-up test.
Conclusions The Veterans Health Administration rates for colorectal cancer screening are significantly higher than the national average.
However, 41 percent of patients with positive fecal occult blood tests failed to receive follow-up testing. Efforts to measure
the quality of colorectal cancer screening programs should focus on the entire diagnostic process.
Supported by the Robert Wood Johnson Foundation Clinical Scholars Program (Etzioni), Department of Veterans Affairs (VA) Health
Services Research and Development (HSR&D), and National Cancer Institute Colorectal Cancer (CRC) Quality Enhancement Research
Initiative (QUERI) Service Directed Research (Project # CRS 02-163).
The views expressed in this article are those of the authors and do not necessarily represent the views of the Robert Wood
Johnson Foundation or the Department of Veterans Affairs. 相似文献
11.
Dr. Wayne C. McCormick MD MPH Thomas S. Inui ScM MD Richard A. Deyo MD MPH Robert W. Wood MD 《Journal of general internal medicine》1991,6(6):524-528
Objective:To determine in a cohort of hospitalized persons with AIDS: 1) their preferences for various postdischarge long-term care
settings, 2) the postdischarge settings recommended by primary care providers (doctors, nurses, and social workers), and 3)
the impact of these views on the resulting discharge dispositions.
Design:Prospective cohort study.
Setting:Medical wards of five Seattle tertiary care hospitals.
Participants:120 consecutive hospitalized persons with AIDS and their primary care providers.
Measurements and main results:Although 70 (58%) of the patients found care in an AIDS long-term care facility acceptable, 87 (73%) preferred home care.
Thirty-eight (32%) of the cohort were appropriate for long-term care after hospitalization, according to primary care providers.
Eleven of the 38 patients deemed appropriate for long-term care were discharged to long-term care settings; among these, three
had preferred home care. Likelihood of discharge to long-term care settings increased if patients found it acceptable (OR=7.1;
95% CI=3.2, 15.5), if they did not prefer home care (OR=7.7; 95% CI=4.7, 13.5), and if providers judged them to be appropriate
for long-term care (OR=29; 95% CI=13, 64). In unstructured interviews, availability of emotional and medical support and privacy
emerged as important factors to persons with AIDS considering long-term care.
Conclusions:Hospitalized persons with AIDS willingly express their desires for various postdischarge care settings. A majority find long-term
care in AIDS facilities acceptable, although they generally prefer home care. Discharge disposition is associated with acceptability,
preference, and appropriateness for long-term care.
Presented in part at the Vth International Conference on AIDS, Montreal, Quebec, Canada, June 5, 1989. Also presented in part
at the 14th annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1–3, 1991.
Supported in part by the Northwest Health Services Research and Development Field Program (Seattle VA Medical Center) and
the Seattle/King County Department of Public Health, AIDS Prevention Project. Dr. McCormick was a fellow in the Robert Wood
Johnson Clinical Scholars Program during this project.
The opinions stated herein are those of the authors and may not represent the views of the Robert Wood Johnson Foundation
or the Department of Veterans Affairs. 相似文献
12.
Dr. Barbara J. Turner MD MSEd Leona Markson ScD James Cocroft MA Leon Cosler PhD Walter W. Hauck PhD 《Journal of general internal medicine》1998,13(1):16-23
OBJECTIVE: To examine the association of clinic HIV-focused features and advanced HIV care experience with Pneumocystis carinii pneumonia (PCP) prophylaxis and development of PCP as the initial AIDS diagnosis.
DESIGN: Nonconcurrent prospective study.
SETTING: New York State Medicaid Program.
PARTICIPANTS: Medicaid enrollees diagnosed with AIDS in 1990–1992.
MEASUREMENTS AND MAIN RESULTS: We collected patient clinical and health care data from Medicaid files, conducted telephone interviews of directors of 125
clinics serving as the usual source of care for study patients, and measured AIDS experience as the cumulative number of AIDS
patients treated by the study clinics since 1986. Pneumocystis carinii pneumonia prophylaxis in the 6 months before AIDS diagnosis and PCP at AIDS diagnosis were the main outcome measures. Bivariate
and multivariate analyses adjusted for clustering of patients within clinics. Of 1,876 HIV-infected persons, 44% had PCP prophylaxis
and 38% had primary PCP. Persons on prophylaxis had 20% lower adjusted odds of developing PCP (95% confidence interval [CI]
0.64, 0.99). The adjusted odds of receiving prophylaxis rose monotonically with the number of HIV-focused features offered
by the clinic, with threefold higher odds (95% CI 1.6, 5.7) for six versus two or fewer such features. Patients in clinics
with three HIV-focused features had 36% lower adjusted odds of PCP than those in clinics with one or none. Neither clinic
experience nor specialty had a significant association with prophylaxis or PCP.
CONCLUSIONS: PCP prevention in our study cohort appears to be more successful in clinics offering an array of HIV-focused features.
Presented in part at the 19th Annual Meeting of the Society of General Internal Medicine, Washington, DC, May 1996, and the
Eleventh International Conference on AIDS, Vancouver, BC, Canada, July 1996.
Funded by the Agency for Health Care Policy and Research (RO1 HS06465-04). 相似文献
13.
There is limited understanding of the physical health, mental health, and substance use or abuse correlates of sexual violence
against homeless women. This study documents the association of rape with health and substance use or abuse characteristics
reported by a probability sample of 974 homeless women in Los Angeles. Controlling for potential confounders, women who reported
rape fared worse than those who did not on every physical and mental health measure and were also more likely to have used
and abused drugs other than alcohol. Results should serve to alert clinicians about groups of homeless women who may benefit
from rape screening and treatment interventions.
Presented, in part, at the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) Second National Conference
on Women in Los Angeles, Calif, June 1999.
The research presented here was supported by a grant to Suzanne Wenzel from The Commonwealth Fund, and by a grant to Lillian
Gelberg from the Agency for Health Care Policy and Research. Dr. Gelberg is a Robert Wood Johnson Foundation Generalist Physician
Faculty Scholar. 相似文献
14.
Thomas H. Gallagher MD Bernard Lo MD Margaret Chesney PhD Kate Christensen MD 《Journal of general internal medicine》1997,12(11):663-668
Objective To determine how physicians respond to a request for an expensive, unindicated test.
Design Cross-sectional observational study.
Setting Four sites of a group-model HMO.
Participants Thirty-nine internist volunteers.
Intervention A standardized patient requesting magnetic resonance imaging (MRI) of the head to rule out multiple sclerosis (MS) was inserted
unanncounced into physicians’ regular schedules. The patient’s only complaint was fatigue with no neurologic symptoms.
Measurements and main results Physicians and standardized patients completed assessments after each visit. Thirty-five (90%) of 39 physicians “had no idea”
that the patient they saw was the standardized patients, and the remaining four participants (10%) were only “somewhat suspicious”.
Three (8%) of the physicians agreed to the MRI at the initial visit, and eight (22%) said they might order an MRI in the future.
All doctors who refused the MRI told the patient this was based on lack of a medical indication for the test; seven (19%)
also cited the test’s expense. Twenty physicians (53%) of 38 agreed to a neurology referral. In response to the standardized
patient’s concerns, nine physicians (23%) verbalized that MS is scary, and four (10%) asked the patients about their friend’s
experience with MS. A few physicians appeared to dismiss the patient’s concerns, such as by telling the patient they were
being “paranoid”.
Conclusions Few physicians agreed to a standardized patient’s request for a medically unindicated MRI, but more than half agreed to refer
this patients to a specialist. As physicians practice cost-conscious medicine, they may need to focus on good communication
to maintain patient satisfaction.
Presented in part at the Robert Wood Johnson Clinical Scholars Program national meeting, November 1995 and the Society of
General Internal Medicine national meeting, May 1996.
Supported by grants from the Walter and Elise Haas Fund and the Robert Wood Johnson Clinical Scholars Program. 相似文献
15.
Dr. John F. Steiner MD MPH Stephan D. Fihn MD MPH Thomas D. Koepsell MD MPH Barbara Blair RN C MN Kathy Kelleher RN C MN Dianne D’Alessandro RN MSN Thomas S. Inui ScM MD 《Journal of general internal medicine》1990,5(3):203-210
Objective:To demonstrate that some hypertensive patients under good blood pressure (BP) control can reduce medications, and to identify
predictors of successful reduction.
Design:Observational study with 11-month follow-up.
Setting:Outpatient hypertension clinic at the Seattle Veterans Administration Hospital.
Patients:59 males (51% of those eligible) with diastolic BP<95 mm Hg for ≥6 months; 57 patients (97%) completed the study.
Intervention:Gradual reduction of medications unless diastolic BP rose above 95 mm Hg.
Measurements and main results:Intensity of treatment with BP medications was assessed using a scale of their comparative “vigors.” 35 patients (59%) reduced
medications successfully. By the end of the study, systolic BP had risen by 8.2±12.3 mm Hg (mean±SD) in successful patients,
while diastolic BP did not change significantly. Two predictors of treatment reduction were statistically significant in both
univariate and multivariate analyses: successful patients had been treated more intensively (2.7±1.7 vs. 1.3±0.5 “vigor units,”
p=0.0001), and they had been enrolled in the clinic longer (5.5±3.0 vs. 3.1±2.3 years, p=0.003). Lower systolic BP, higher
urinary sodium excretion, lower compliance, and younger age were significant predictors of treatment reduction on univariate
analysis only. Age≤65 years had the highest sensitivity (86%) for treatment reduction, while treatment with two or more “vigor
units” had the highest specificity (79%) and likelihood ratio (3.3).
Conclusions:Treatment reduction is feasible in many well-controlled hypertensives, though systolic BP rises. Patients with high intensity
and long duration of treatment are most likely to reduce medications successfully.
Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, April 1988, and
the annual meeting of the Robert Wood Johnson Clinical Scholars Program, Miami, Florida, October 1988.
This study was conducted while Dr. Steiner was a Robert Wood Johnson Clinical Scholar at the University of Washington. Support
was provided by the Northwest Health Services Research and Development Program of the Veterans Administration.
The opinions, conclusions, and proposals in this paper are those of the authors, and do not necessarily represent the views
of the Robert Wood Johnson Foundation or the Veterans Administration. 相似文献
16.
Halpern J 《Journal of general internal medicine》2007,22(5):696-700
Physicians associate empathy with benevolent emotions and with developing a shared understanding with patients. While there
have been many articles on managing “difficult” patients, little attention has been paid to the challenges physicians face
during conflicts with patients, especially when both parties are angry and yet empathy is still needed. This topic is especially
important in light of recent studies showing that practicing medicine increasingly requires physicians to manage their own
feelings of anger and frustration. This article seeks to describe how physicians can learn to empathize with patients even
when they are both subject to emotions that lead to interpersonal distancing. Empathy is defined as engaged curiosity about
another’s particular emotional perspective. Five specific ways for physicians to foster empathy during conflict are described:
recognizing one’s own emotions, attending to negative emotions over time, attuning to patients’ verbal and nonverbal emotional
messages, and becoming receptive to negative feedback. Importantly, physicians who learn to empathize with patients during
emotionally charged interactions can reduce anger and frustration and also increase their therapeutic impact.
This work was supported by the Greenwall Foundation and the Berkeley Consortium on Population Health and Human Development,
with funding from the National Institute of Mental Health (R21MH70950) and the Robert Wood Johnson Foundation Health & Society
Scholars Program. 相似文献
17.
Dr. Sana Loue JD PhD Donald J. Slymen PhD Hal Morgenstern PhD Christopher Whalen MD MS 《Journal of general internal medicine》1995,10(8):461-463
To examine the relationship between health insurance status and health services utilization among HIV-infected patients with
activePneumocystis carinii pneumonia (PCP), the discharge and outpatient databases of a large California medical facility were reviewed. Four hundred
fifty records met the inclusion criteria. Logistic regression indicated that those who had publicly funded insurance were
about half as likely (95% CI 0.28,0.99) as were those who had private insurance to undergo bronchoscopy with bronchoalveolar
lavage at the time of their first PCP episodes. Further research is required to identify the reasons for this difference.
Supported in part by Grant R014506211 from the Agency for Health Care Policy and Research and a traineeship from the National
Institute of Mental Health (SL). 相似文献
18.
OBJECTIVE: To identify the desired features of end-of-life medical decision making from the perspective of elderly individuals.
DESIGN: Qualitative study using in-depth interviews and analysis from a phenomenologic perspective.
SETTING: A senior center and a multilevel retirement community in Los Angeles.
PARTICIPANTS: Twenty-one elderly informants (mean age 83 years) representing a spectrum of functional status and prior experiences with
end-of-life decision making.
MAIN RESULTS: Informants were concerned primarily with the outcomes of serious illness rather than the medical interventions that might
be used, and defined treatments as desirable to the extent they could return the patient to his or her valued life activities.
Advanced age was a relevant consideration in decision making, guided by concerns about personal losses and the meaning of
having lived a “full life.” Decisionmaking authority was granted both to physicians (for their technical expertise) and family
members (for their concern for the patient’s interests), and shifted from physician to family as the patient’s prognosis for
functional recovery became grim. Expressions of care, both by patients and family members, were often important contributors
to end-of-life treatment decisions.
CONCLUSIONS: These findings suggest that advance directives and physician-patient discussions that focus on acceptable health states and
valued life activities may be better suited to patients’ end-of-life care goals than those that focus on specific medical
interventions, such as cardiopulmonary resuscitation. We propose a model of collaborative surrogate decision making by families
and physicians that encourages physicians to assume responsibility for recommending treatment plans, including the provision
or withholding of specific life-sustaining treatments, when such recommendations are consistent with patients’ and families’
goals for care.
This research was partially funded by the Robert Wood Johnson Clinical Scholars Program. The views expressed above are those
of the authors and do not necessarily reflect those of the Robert Wood Johnson Foundation. 相似文献
19.
Conclusions Care of the pregnant woman who has a medical illness requires careful coordination between the consulting general internist,
subspecialist, and obstetrician. When possible, this care should be initiated prior to conception to optimize medical management
and, when appropriate, initiate genetic counseling. Many diagnostic and therapeutic choices must be made without good scientific
data. Yet, most of the time, outcomes are favorable. Few disciplines within internal medicine provide such a rich, yet demanding,
challenge to the consulting internist.
Received from the Division of General Internal Medicine, Department of Medicine, University of Medicine and Dentistry of New
Jersey/Robert Wood Johnson Medical School, New Brunswick, New Jersey, and the Division of General Medicine, Department of
Medicine, The Oregon Health Sciences University, Portland, Oregon. 相似文献
20.
Bradley KA Epler AJ Bush KR Sporleder JL Dunn CW Cochran NE Braddock CH McDonell MB Fihn SD 《Journal of general internal medicine》2002,17(5):315-326
OBJECTIVE: This study describes primary care discussions with patients who screened positive for at-risk drinking. In addition, discussions
about alcohol use from 2 clinic firms, one with a provider-prompting intervention, are compared.
DESIGN: Cross-sectional analyses of audiotaped appointments collected over 6 months.
PARTICIPANTS AND SETTING: Male patients in a VA general medicine clinic were eligible if they screened positive for at-risk drinking and had a general
medicine appointment with a consenting provider during the study period. Participating patients (N=47) and providers (N=17) were enrolled in 1 of 2 firms in the clinic (Intervention or Control) and were blinded to the study focus.
INTERVENTION: Intervention providers received patient-specific results of positive alcohol-screening tests at each visit.
MEASURES AND MAIN RESULTS: Of 68 visits taped, 39 (57.4%) included any mention of alcohol. Patient and provider utterances during discussions about
alcohol use were coded using Motivational Interviewing Skills Codes. Providers contributed 58% of utterances during alcohol-related
discussions with most coded as questions (24%), information giving (23%), or facilitation (34%). Advice, reflective listening,
and supportive or affirming statements occurred infrequently (5%, 3%, and 5%, of provider utterances respectively). Providers
offered alcohol-related advice during 21% of visits. Sixteen percent of patient utterances reflected “resistance” to change
and 12% reflected readiness to change. On average, Intervention providers were more likely to discuss alcohol use than Control
providers (82.4% vs 39.6% of visits; P=.026).
CONCLUSIONS: During discussions about alcohol, general medicine providers asked questions and offered information, but usually did not
give explicit alcohol-related advice. Discussions about alcohol occurred more often when providers were prompted.
This research was supported by grants from the University of Washington Royalty Research Fund, and the Department of Veterans
Affairs, Health Services Research and Development Service (SDR 96-002). Dr. Bradley is an investigator at the VA Puget Sound
Health Care System, and is currently supported by National Institute of Alcohol Abuse and Alcoholism grant no. K23AA00313)
and is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar. Views expressed in this article are those of
the authors and do not necessarily represent the views of the Department of Veterans Affairs, the University of Washington,
the National Institute of Alcohol Abuse and Alcoholism, or the Robert Wood Johnson Foundation. 相似文献