Submitting articles to the BMJ

ObjectiveTo investigate how doctors engage with patients with psychotic illness in routine consultations.DesignConversation analysis of 32 consultations between psychiatrists and patients with schizophrenia or schizoaffective disorder.SettingTwo psychiatric outpatient clinics in east London and south west London.Participants7 psychiatrists and 32 patients with schizophrenia or schizoaffective disorder.ResultsPatients actively attempted to talk about the content of their psychotic symptoms in consultations by asking direct questions, repeating their questions and utterances, and producing these utterances in the concluding part of the consultation. In response, doctors hesitated, responded with a question rather than with an answer, and smiled or laughed (when informal carers were present), indicating that they were reluctant to engage with patients'' concerns about their psychotic symptoms.ConclusionsPatients repeatedly attempted to talk about the content of their psychotic symptoms, which was a source of noticeable interactional tension and difficulty. Addressing patients'' concerns about their illness may lead to a more satisfactory outcome of the consultation and improve engagement of such patients in the health services.

What is already known on this topic

Patients with psychotic illness are difficult to engage in the health servicesNo research has been published on how doctors engage with these patients in consultations

What this study adds

Patients actively attempt to talk about the content of their psychotic symptomsDoctors'' reluctance and discomfort in engaging with this topic is apparentAddressing patients'' concerns may lead to a more satisfactory outcome of the consultation and improve engagement with services     

Sexual Therapy of Patients with Cardiovascular Disease

Physical illness or disability inevitably has a damaging effect on sexual relationships. Physicians are usually unaware of the sexual consequences of illness on their patients, and lack experience in treating sexual dysfunctions.The report of treatment of a couple with serious cardiovascular disease illustrates the potential efficacy of brief sex therapy for improving the quality of a patient''s life. If a primary physician lacks the skills to conduct sex therapy, he may collaborate with nonphysician therapists. The physician''s knowledge of the physiological and psychological effects of a specific illness on his patient is essential to successful therapy. Often, simple education, encouragement or reassurance by the physician is enough to overcome the damaging effects of illness on a patient''s sex life.     

Palliative care: views of patients and their families.

OBJECTIVE--To investigate the current problems and needs of terminally ill cancer patients and their family members, and to discover their views of hospital, community, and support team services. DESIGN--Prospective study of patients and families by questionnaire interviews in the patients'' homes. SETTING--Inner London and north Kent (London suburbs). SUBJECTS--65 Patients, each with a member of their family or a career. MAIN OUTCOME MEASURES--Ratings of eight current problems and ratings and comments on three services-hospital doctors and nurses, general practitioners and district nurses, and the support team staff-obtained after a minimum of two weeks'' care from palliative care support teams. RESULTS--Effect of anxiety on the patient''s nearest career. and symptom control were rated as the most severe current problems by both patients and families; a few patients and families identified other severe problems. Families'' ratings of pain control, symptom control, and effect of anxiety on the patient were significantly worse than the patients'' ratings (p less than 0.05). Support teams received the most praise, being rated by 58 (89%) patients and 59 (91%) of family members as good as excellent. General practitioners and district nurses were rated good or excellent by 46 (71%) patients and 46 (71%) family members, but six (9%) in each group rated the service as poor or very bad, and ratings in the inner London district were significantly worse than those in the outer London district. Hospital doctors and nurses were rated good or excellent by 22 (34%) patients and 35 (54%) of family members, and 14 (22%) patients and 15 (23%) family members rated this service as poor or very bad. Negative comments referred to communication (especially at diagnosis), coordination of services, the attitude of the doctor, delays in diagnosis, and difficulties in getting doctors to visit at home. Family members were more satisfied with the services than were patients. CONCLUSIONS--Palliative care needs to include both the patient and family because the needs of the family may exceed those of the patient. Support teams and some hospital and community doctors and nurses met the perceived needs of dying patients and families, but better education and organisation of services are needed.     

PSYCHOTHERAPY—A Concept for the Nonpsychiatric Physician

Patients tend to repeat with their physician, as with other significant people in their lives, their earlier previous patterns of behavior. The physician as well as the patient is involved in the physician-patient relationship. He will tend to respond to his patients in accordance with his earlier life experiences and his characteristic repetitive behavioral pattern. For both physician and patient, the relationship between them extends beyond the immediate reality situation.Psychotherapy is the utilization of psychological measures in the treatment of sick persons and the deliberate utilization by the physician of the physician-patient relationship for the benefit of the patient. The kind of psychotherapy that is practical and utilizable by the nonpsychiatric physician is that which uses education, reassurance, support and the management of the patient''s problems either directly or indirectly or through the intermediary of other people or agencies.The symbolic aspect of the physician-patient relationship is based essentially on the fact that a sick person, because of his anxiety and because of the threat to his physical and psychic integrity, is more dependent and more anxious than he would be if he were well, and therefore he has a correspondingly greater need for the authoritative and protective figure he finds in the physician.Psychotherapy is not directed exclusively to the treatment of flagrantly or obviously neurotic or psychotic patients. It should be and is directed to all sick persons. Limitations in psychotherapy are set by various determinants, among which are the nature of the precipitating factor in the illness, the nature of the sick person, the skill, knowledge and abilities of the physician, and the nature of the physician-patient relationship. In psychotherapy, as in all medicine, the physician should not do anything which may disturb the patient if the disturbance is of no value or if it cannot be followed through with special skills.     

慢性阻塞性肺疾病急性加重对患者生活质量的影响

目的:探讨慢性阻塞性肺疾病急性加重对患者生活质量的影响。方法:以中国中医科学院广安门医院呼吸科长期慢病管理计划中确诊的慢性阻塞性肺疾病患者为研究对象,记录其在2013年1月至12月间发生的慢性阻塞性肺疾病急性加重事件的情况,并采用面对面访谈式问卷调查方法,在2013年12月对患者进行肺疾病评估测试、焦虑自评量表评分及抑郁自评量表评分,以探讨急性加重发生对患者健康的影响。结果:504例慢性阻塞性肺疾病患者中,过去1年间220例(43.7%)有急性加重发作,其CAT评分、SAS评分、SDS评分均高于未发生急性加重患者,差异均有统计学意义(P0.05)。急性加重发作患者中,66.4%的生活质量均受到中等程度及以上影响,高于无急性加重发生组(52.1%),差异有统计学意义(P0.05)。此外,有急性加重发作的患者合并焦虑和/或抑郁状态的患病率也高于无急性加重发作的患者,差异有统计学意义(P0.05)。结论:慢性阻塞性肺疾病急性加重对患者生活质量、精神状态均可能产生不利影响。     

Physician communication skills and malpractice claims. A complex relationship.

We assessed the relationship between patients'' opinions about their physicians'' communication skills and the physician''s history of medical malpractice claims. The sample consisted of 107 physicians and 2,030 of their patients who had had an operation or a delivery. Although patients tended to give their physicians favorable ratings, they were least satisfied with the amount of explanations they received. Patients gave higher ratings to general surgeons and obstetrician-gynecologists and poorer ratings to orthopedists and anesthesiologists. Women and better-educated patients gave higher ratings on explanations and communication to physicians with fewer claims. Men and patients with less education, however, gave higher ratings on these dimensions to physicians with more claims. These findings suggest the need for physicians to tailor their communications to a patient''s individual needs. Improved communication between physicians and patients may result in fewer nonmeritorious malpractice claims while leading to less costly resolution of meritorious claims.     

Role of patients' view of their illness in predicting return to work and functioning after myocardial infarction: longitudinal study.

OBJECTIVE--To examine whether patients'' initial perceptions of their myocardial infarction predict subsequent attendance at a cardiac rehabilitation course, return to work, disability, and sexual dysfunction. DESIGN--Patients'' perceptions of their illness were measured at admission with their first myocardial infarction and at follow up three and six months later. SETTING--Two large teaching hospitals in Auckland, New Zealand. SUBJECTS--143 consecutive patients aged under 65 with their first myocardial infarction. MAIN OUTCOME MEASURES--Attendance at rehabilitation course; time before returning to work; measures of disability with sickness impact profile questionnaire for sleep and rest, social interaction, recreational activity, and home management; and sexual dysfunction. RESULTS--Attendance at the rehabilitation course was significantly related to a stronger belief during admission that the illness could be cured or controlled (t = 2.08, P = 0.04). Return to work within six weeks was significantly predicted by the perception that the illness would last a short time (t = 2.52, P = 0.01) and have less grave consequences for the patient (t = 2.87, P = 0.005). Patients'' belief that their heart disease would have serious consequences was significantly related to later disability in work around the house, recreational activities, and social interaction. A strong illness identity was significantly related to greater sexual dysfunction at both three and six months. CONCLUSIONS--Patients'' initial perceptions of illness are important determinants of different aspects of recovery after myocardial infarction. Specific illness perceptions need to be identified at an early stage as a basis for optimising outcomes from rehabilitation programmes.     

Evaluation of a stroke family care worker: results of a randomised controlled trial.

OBJECTIVE: To examine the effect of contact with a stroke family care worker on the physical, social, and psychological status of stroke patients and their carers. DESIGN: Randomised controlled trial with broad entry criteria and blinded outcome assessment six months after randomisation. SETTING: A well organised stroke service in an Edinburgh teaching hospital. SUBJECTS: 417 patients with an acute stroke in the previous 30 days randomly allocated to be contacted by a stroke family care worker (210) or to receive standard care (207). The patients represented 67% of all stroke patients assessed at the hospital during the study period. MAIN OUTCOME MEASURES: Patient completed Barthel index, Frenchay activities index, general health questionnaire, hospital anxiety and depression scale, social adjustment scale, mental adjustment to stroke scale, and patient satisfaction questionnaire; carer completed Frenchay activities index, general health questionnaire, hospital anxiety and depression scale, social adjustment scale, caregiving bassles scale, and carer satisfaction questionnaire. RESULTS: The groups were balanced for all important baseline variables. There were no significant differences in physical outcomes in patients or carers, though patients in the treatment group were possibly more helpless less well adjusted socially, and more depressed, whereas carers in the treatment group were possibly less hassled and anxious. However, both patients and carers in the group contacted by the stroke family care worker expressed significantly greater satisfaction with certain aspects of their care, in particular those related to communication and support. CONCLUSIONS: The introduction of a stroke family care worker improved patients'' and their carers'' satisfaction with services and may have had some effect on psychological and social outcomes but did not improve measures of patients'' physical wellbeing.     

Diagnostic and therapeutic efficacy of barium meal examination: a prospective evaluation in general practice.

OBJECTIVE--To assess the efficacy of barium meal examinations in managing patients with dyspepsia in general practice. DESIGN--Prospective study by questionnaires completed by general practitioners before and within three to six months after the barium meal examination. Information was requested about the patients'' symptoms, current treatment, reason for requesting the examination, and the working diagnosis, including degree of certainty and, after the examination, about any change in diagnosis, diagnostic confidence, or management and to determine whether the examination was judged to be helpful or not. SETTING--Inner city health district. PATIENTS--133 Patients with dyspepsia referred by general practitioners for outpatient barium meal examination, 31 of whom failed to attend for the examination, or refused it on arrival, or did not have fully completed questionnaires. Two patients were not available for follow up. MAIN OUTCOME MEASURES--Prevalence of radiological abnormalities and the influence of the examination result on management, particularly changes in drug treatment. RESULTS--Fully completed pairs of questionnaires were available for 100 patients, 58 of whom were aged below 50. Most of the barium meal reports (64) were to confirm the clinical diagnosis; only 22 were to exclude serious disease. Ninety nine patients were already receiving treatment, with 39 taking an H2 receptor antagonist. Fifty eight barium meal examinations showed abnormalities (31 major abnormalities); there were no cancers and in only 18 patients was the working diagnosis changed as a result of the findings. Although the barium meal result increased management confidence (63 patients) and allayed patients'' anxiety (46), changes in management attributed directly to the examination occurred in only 22 patients. Management changes were minor, usually comprising interchange of antacids and H2 receptor antagonists. CONCLUSIONS--Young patients (aged below 50) with dyspepsia are still being overinvestigated. Although barium meal examination improves diagnostic confidence and allays patients'' anxiety, fully utilising communication skills at the initial consultation might allay anxiety more economically.     

Performing arts medicine.

Arts medicine has come of age, resulting from 3 important developments over the past decade: improved methods of diagnosis and treatment, an awareness that artists suffer from special problems related to their occupation and lifestyle, and the establishment of health programs emphasizing an interdisciplinary approach to these patients. We focus on the patterns of illness afflicting performing artists, specifically dancers, singers, actors, and instrumental musicians, and explain some of the things a health care team can do in treating these patients. The conditions governing these patients'' lives--early exposure to high expectations of excellence, incessant demands for perfection, long periods of intense practicing, fierce competition, high levels of anxiety associated with performance, and uncertain careers--need to be understood. Levels of disease and disability are remarkably high, but artists often ignore symptoms. We discuss the musculoskeletal, neurologic, vocal, psychological, and other syndromes found among performers and some of the difficulties in treating them. The prevention of injury, conservative management, collaboration with teachers, and a psychotherapeutic approach are desirable. Arts medicine programs for professional consultation exist in several major cities of the United States and abroad. Although research is needed regarding the effectiveness of health care services for performing artists, the scientific literature devoted to this field is growing.     

Study on the Effects of Tablet Colour in the Treatment of Anxiety States

Forty-eight patients with anxiety states were treated with oxazepam (Serenid-D), which was administered in tablets of three different colours—red, yellow, and green. Every patient received one week''s treatment with each colour, according to a random programme. A latin square design was used to ensure complete balance between the colours and between the weeks. The patients'' symptoms were categorized and then assessed by both weekly physicians'' ratings and daily self-rating, which showed close agreement. Colour preference was shown on both these scales in that symptoms of anxiety were most improved with green, whereas depressive symptoms appeared to respond best to yellow. Such colour preferences, however, did not reach levels of statistical significance, except for phobias as rated on the physicians'' assessment.The results indicate that colour may play a part in the response to a drug.     

Gender Differences in patient-provider symptom agreement in reporting respiratory complaints on a questionnaire

Background: Men and women communicate differently, but it is unclear whether this influences health care outcomes.Objective: Because women patients frequently choose women health care providers, we examined whether this preference was affected by communication styles. We focused on communication of disease-specific symptoms, hypothesizing that symptom agreement between women patients and women health care providers would be greater than between other patient-provider gender combinations.Methods: Patients attending outpatient clinics were recruited as part of a study of respiratory illness at 7 university-affiliated sites during 3 consecutive influenza seasons (2000–2003). Individuals aged ≥ 19 years were offered enrollment if they sought care for cold or flu symptoms at a participating study site. Patients were eligible to participate in the study if they reported any 1 of 6 symptoms: cough, runny nose, fever (subjective), muscle aches, sore throat, and/or exhaustion. Using separate questionnaires, patients and their health care providers recorded the patients' respiratory symptoms (as present or absent). Patients recorded their symptoms before visiting their health care provider, and providers recorded patient symptoms after the visit. Symptom agreement was compared using general estimating equations across all gender combinations.Results: A total of 327 patients (220 women, 107 men) and 84 health care providers (37 women, 47 men) participated in the study. Overall symptom agreement for all patient-provider gender combinations was 81.9% (95% CI, 79.6%–84.2%). For each symptom, the observed agreement significantly exceeded the agreement expected by chance alone (P < 0.001 for all symptoms except “no energy,” which was P = 0.023). The male-male pairing of patient and provider was more likely to agree on a symptom than were the other gender combinations, although not statistically significantly more so than the female-female pairing.Conclusions: In this survey of patients with respiratory illness, there was no significant difference in symptom agreement for most symptoms between the male-male and female-female patient-provider combinations. Based on these findings, symptom agreement alone does not explain why women patients select women health care providers.     

Awareness of Memory Deficits in Early Stage Huntington's Disease

Patients with Huntington''s disease (HD) are often described as unaware of their motor symptoms, their behavioral disorders or their cognitive deficits, including memory. Nevertheless, because patients with Parkinson''s disease (PD) remain aware of their memory deficits despite striatal dysfunction, we hypothesize that early stage HD patients in whom degeneration predominates in the striatum can accurately judge their own memory disorders whereas more advanced patients cannot. In order to test our hypothesis, we compared subjective questionnaires of memory deficits (in HD patients and in their proxies) and objective measures of memory dysfunction in patients. Forty-six patients with manifest HD attending the out-patient department of the French National Reference Center for HD and thirty-three proxies were enrolled. We found that HD patients at an early stage of the disease (Stage 1) were more accurate than their proxies at evaluating their own memory deficits, independently from their depression level. The proxies were more influenced by patients'' functional decline rather than by patients'' memory deficits. Patients with moderate disease (Stage 2) misestimated their memory deficits compared to their proxies, whose judgment was nonetheless influenced by the severity of both functional decline and depression. Contrasting subjective memory ratings from the patients and their objective memory performance, we demonstrate that although HD patients are often reported to be unaware of their neurological, cognitive and behavioral symptoms, it is not the case for memory deficits at an early stage. Loss of awareness of memory deficits in HD is associated with the severity of the disease in terms of CAG repeats, functional decline, motor dysfunction and cognitive impairment, including memory deficits and executive dysfunction.     

Clinician gender is more important than gender concordance in quality of HIV care

Background: Previous studies have examined the impact of physician gender and gender concordance on preventive care, satisfaction, and communication. Less is known about how physician gender and gender concordance affect care for chronic illnesses, including HIV.Objective: This study sought to determine whether patient-clinician gender concordance (patient and clinician are of the same gender) influences receipt of protease inhibitor (PI) therapy and ratings of care among HIV-infected patients.Methods: We reviewed data from 1860 patients and 397 clinicians in the HIV Cost and Services Utilization Study, a nationally representative the association between gender concordance and time to first PI use, and multivariable logistic regression was utilized to examine the association of gender concordance with patients' problems with care and their overall rating of care.Results: Patients who had a male clinician received PIs earlier than those who had a female clinician (adjusted time ratio = 0.69 for having a male vs having a female clinician; P ≤ 0.01). Gender concordance was not a significant predictor of time to PI use. Gender discordance was associated with problems with feeling respected by clinicians. Female patients with a male clinician were most likely, and female patients with female clinicians were least likely, to report a problem with being treated with respect (P ≤ 0.01 for the interaction term). Gender discordance was not associated with other problems with care or with overall ratings of care.Conclusions: Gender discordance was associated with perceived problems of being treated with respect by clinicians, but not with time to receipt of PIs, overall ratings of care, coordination of care, or obtaining information. The perception of not being respected may represent a significant barrier to care that is particularly worse for women, in that most HIV-infected women receive their care from male clinicians.     

Patients' and practitioners' views of knee osteoarthritis and its management: a qualitative interview study

Purpose

To identify the views of patients and care providers regarding the management of knee osteoarthritis (OA) and to reveal potential obstacles to improving health care strategies.

Methods

We performed a qualitative study based on semi-structured interviews of a stratified sample of 81 patients (59 women) and 29 practitioners (8 women, 11 general practitioners [GPs], 6 rheumatologists, 4 orthopedic surgeons, and 8 [4 GPs] delivering alternative medicine).

Results

Two main domains of patient views were identified: one about the patient–physician relationship and the other about treatments. Patients feel that their complaints are not taken seriously. They also feel that practitioners act as technicians, paying more attention to the knee than to the individual, and they consider that not enough time is spent on information and counseling. They have negative perceptions of drugs and a feeling of medical uncertainty about OA, which leads to less compliance with treatment and a switch to alternative medicine. Patients believe that knee OA is an inevitable illness associated with age, that not much can be done to modify its evolution, that treatments are of little help, and that practitioners have not much to propose. They express unrealistic fears about the impact of knee OA on daily and social life. Practitioners'' views differ from those of patients. Physicians emphasize the difficulty in elaborating treatment strategies and the need for a tool to help in treatment choice.

Conclusions

This qualitative study suggests several ways to improve the patient–practitioner relationship and the efficacy of treatment strategies, by increasing their acceptability and compliance. Providing adapted and formalized information to patients, adopting more global assessment and therapeutic approaches, and dealing more accurately with patients'' paradoxal representation of drug therapy are main factors of improvement that should be addressed.     

Hypoprothrombinemic hemorrhage due to cholestyramine therapy.

Somatization is the tendency to experience and communicate psychologic distress in the form of somatic symptoms that the patient misinterprets as signifying serious physical illness. Patients with persistent somatization relentlessly seek medical diagnosis and treatment despite repeated reassurance that physical illness is either absent or insufficient to account for their symptoms and disability. Such abnormal illness behaviour leads to overuse of health care facilities and contributes to the high cost of health care. Somatization may occur transiently in response to stressful life events or it may be persistent and result in chronic partial or total disability. Diagnostic and therapeutic guidelines that may help physicians identify and manage such patients more effectively are discussed.     

Comparison of patient and surgeon expectations of total hip arthroplasty

Objectives

Analysis of discrepancies between patient and surgeon expectations before total hip arthroplasty (THA) should enable a better understanding of motives of dissatisfaction about surgery, but this question has been seldom studied. Our objectives were to compare surgeons'' and patients'' expectations before THA, and to study factors which affected surgeon-patient agreement.

Methods

132 adults (mean age 62.8+/−13.7 years, 52% men) on waiting list for THA in three tertiary care centres and their 16 surgeons were interviewed to assess their expectations using the Hospital for Special Surgery Total Hip Replacement Expectations Survey (range 0–100). Patients'' and surgeons'' answers were compared, for the total score and for the score of each item. Univariate analyses tested the effect of patients'' characteristics on surgeons'' and patients'' expectations separately, and on surgeon-patient differences.

Results

Surgeon and patient expectations'' mean scores were high (respectively 90.9+/−11.1 and 90.0+/−11.6 over 100). Surgeons'' and patients'' expectations showed no systematic difference, but there was little agreement on Bland and Altman graph and correlation coefficient was low. Patients had higher expectations than surgeons for sports. Patients rated their expectations according to trust in physician and mental quality of life, surgeons considered disability. More disabled patients and patients from a low-income professional category were often “more optimistic” than their surgeons.

Conclusion

Surgeons and patients often do not agree on what to expect from THA. More disabled patients expect better outcomes than their surgeons.     

Strategies for Improving Participation in Diabetes Education. A Qualitative Study

Objective

Diabetes mellitus is highly prevalent and can lead to serious complications and mortality. Patient education can help to avoid negative outcomes, but up to half of the patients do not participate. The aim of this study was to analyze patients'' attitudes towards diabetes education in order to identify barriers to participation and develop strategies for better patient education.

Methods

We conducted a qualitative study. Seven GP practices were purposively selected based on socio-demographic data of city districts in Hamburg, Germany. Study participants were selected by their GPs in order to increase participation. Semi-structured face-to-face interviews were conducted with 14 patients. Interviews were audiotaped and transcribed verbatim. The sample size was determined by data saturation. Data were analysed by qualitative content analysis. Categories were determined deductively and inductively.

Results

The interviews yielded four types of barriers: 1) Statements and behaviour of the attending physician influence the patients'' decisions about diabetes education. 2) Both, a good state of health related to diabetes and physical/psychosocial comorbidity can be reasons for non-participation. 3) Manifold motivational factors were discussed. They ranged from giving low priority to diabetes to avoidance of implications of diabetes education as being confronted with illness narratives of others. 4) Barriers also include aspects of the patients'' knowledge and activity.

Conclusions

First, physicians should encourage patients to participate in diabetes education and argue that they can profit even if actual treatment and examination results are promising. Second, patients with other priorities, psychic comorbidity or functional limitations might profit more from continuous individualized education adapted to their specific situation instead of group education. Third, it might be justified that patients do not participate in diabetes education if they have slightly increased blood sugar values only and no risk for harmful consequences or if they already have sufficient knowledge on diabetes.     

The psychological and social effects of myocardial infarction on wives.

Eighty-two wives of men suffering a first myocardial infarction were interviewed while their husbands were in hospital, and again two months and a year after they went home. The wives had substantial and persistent psychological symptoms, and the husbands'' illness had continuing effects on their work, leisure and social activities, and family life and marriage, their psychosocial disability being comparable to that of the patients. Measures of psychosocial adjustment before the illness and the quality of the marriage and of family life were good predictors of outcome for the wives. The women had a major role in the patients'' readjustment during convalescence, and their attitudes and behaviour as well as the general quality of family life were important determinants of the rate and extent of the patients'' recovery. The wives of patients with myocardial infarction should have more practical help and advice during the hospital period, and the whole family should be given advice and help throughout the convalescence.