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Biomedical subjects

A L Suchman

Publications and source records attributed to A L Suchman.

31 records · Page 2Linked to original sources
PubMed1988

What makes the patient-doctor relationship therapeutic? Exploring the connexional dimension of medical care.

Physicians do not receive from the medical model the same explicit guidance in relating to their patients as in making diagnoses and prescribing pharmacologic and other treatments. To meet this need, we offer a framework for expanding the model. Therapeutic contact takes place within a connexional, or transpersonal, dimension of human experience, within which basic human needs for connection and meaning are met. Although seldom explicitly recognized, connexional experience is basic to medical care. Awareness of this dimension of experience leads clinicians to appreciate that establishing a therapeutic relationship is one of the principal goals of medical practice. It also reframes the doctor's task to make clinical uncertainty more tolerable and situations in which there is no appropriate biomedical response (such as care of the terminally ill) less frustrating and more fulfilling.

History, 15th Century↗
PubMed1986

How well does the activated partial thromboplastin time predict postoperative hemorrhage?

To determine the clinical usefulness of the activated partial thromboplastin time in screening patients before surgery, we related preoperative test results to the occurrence of hemorrhagic complications, studying all adult inpatients undergoing invasive diagnostic or therapeutic procedures at a large university hospital during a one-year period. Using clinical characteristics to divide the population into two groups according to a priori risk of hemorrhagic complications, we found that the activated partial thromboplastin time had no ability to predict the occurrence or absence of hemorrhage in the low-risk group, but that it was a predictor of modest strength in the high-risk group. Our data justify limiting preoperative coagulation screening to patients with active bleeding, known or clinically suspected bleeding disorders (including use of anticoagulants), liver disease, malabsorption, malnutrition, or other conditions associated with acquired coagulopathies and patients whose procedures may interfere with normal coagulation.

Adult↗
PubMed1986

Diagnostic uses of the activated partial thromboplastin time and prothrombin time.

The activated partial thromboplastin time (APTT) and prothrombin time (PT) have three principal uses. In screening for coagulation disorders (or increased risk of postoperative hemorrhage), the tests add no information to the preoperative care of patients without clinical findings indicative of increased bleeding risk. Furthermore, the prevalence of asymptomatic congenital coagulopathies is so low that false-positive test results greatly outnumber true-positive results. Thus, clinicians may use clinical assessment to screen and should reserve coagulation tests to investigate patients with abnormal findings. In evaluating abnormal bleeding, these tests are sufficiently sensitive that if both are negative, further investigation of the coagulation system is obviated. If one or both tests are positive, the pattern of results directs further attention to limited segments of the coagulation sequence. In monitoring anticoagulation therapy, the APTT and PT tests appear to contribute to the safety and effectiveness of heparin and warfarin therapies, respectively.

Anticoagulants↗
PubMed1981

Aggressive plasma cell myeloma. A terminal phase.

Seven patients with plasma cell myeloma experienced an aggressive, terminal phase. This phase is characterized by rapidly enlarging soft-tissue masses with tumor morphologic characteristics similar to a poorly differentiated or large-cell (histiocytic) lymphoma, with rapid death, and often with fever, pancytopenia, decreasing levels of myeloma protein, and younger age. Median survival from the onset of the phase was four months. There was no response to single-agent or combination chemotherapy. In view of the extremely poor prognosis and lack of response to conventional treatment, patients experiencing this characteristic terminal phase should be considered candidates for innovative therapy.

Adult↗
PubMedDate not supplied

The meaning of symptoms in 10 women with somatization disorder and a history of childhood abuse.

OBJECTIVE: To understand the associated experiences and illness behavior in patients with somatization disorder and a history of childhood abuse. DESIGN: In-depth interviews were conducted with patients who had somatization disorder and a history of childhood abuse; qualitative content analysis was then performed. SETTING: Patients were recruited from 2 primary care teaching practices. PARTICIPANTS: Physicians were asked to refer patients suspected of having both conditions, yielding 21 potential participants. Eight declined, and 3 did not meet standardized screening questionnaire criteria, yielding 10 women who participated in the study. Participants and nonparticipants had a similar range of socioeconomic variables. RESULTS: An analysis of the interviews yielded 22 themes. Seven themes relevant to understanding the link between illness behavior and abuse were the abuse experiences, emotional and behavioral reactions to the abuse, relationship of abuse to somatoform symptoms, relationship of abuse to health care use, attempts to tell about the abuse, relationships with physicians, and physician behavior. Childhood attempts to tell adults about the abuse resulted in threats of punishment, contributing to lifelong patterns of secrecy, even with physicians. Six women reported having childhood physicians who were family members, friends, or the abuser's physician, reinforcing their subsequent secrecy. The women reported that their current physicians denied their physical pain as adults, just as the abusers denied their emotional and physical pain in childhood. Seven women reported decreased health care use once they associated symptoms with abuse experiences. Nine women reported spousal abuse. CONCLUSIONS: Somatization and childhood abuse may involve a paradoxical pattern of hiding feelings and reality, while seeking acknowledgment of suffering. Patient insight may decrease health care use. Therefore, the exploration of patient experiences may be useful for women with somatization disorder and a history of childhood abuse. The risks of spousal abuse and denial and rejection in the physician-patient relationship could also be important.

Adolescent↗
PubMedDate not supplied

Does physician uncertainty affect patient satisfaction?

Physicians may choose one of several strategies when initially uncertain about making a specific therapeutic recommendation. The authors investigated how patients' satisfaction is affected by disclosure of uncertainty and its attempted resolution during a clinical encounter. Three hundred and four patients awaiting appointments at a university hospital's ambulatory medical clinic were randomized to view one of five videotapes (VTs) of a patient seeking advice about antimicrobial prophylaxis for a heart murmur. In VT-1 and VT-2, the physician disclosed no uncertainty and prescribed therapy. In VT-3, VT-4, and VT-5, the physician openly conveyed uncertainty but then: (VT-3) prescribed antibiotics without resolving his uncertainty; (VT-4) consulted a reference book with the patient present, then prescribed; or (VT-5) checked a computer with the patient present, then prescribed. Patients rated their satisfaction with the physician on a standardized questionnaire. Differences in satisfaction between the five VTs were significant (p = 0.001), with the highest ratings found for VT-1 and VT-2, where no uncertainty was disclosed. The lowest ratings in satisfaction were found when the physician expressed but then ignored uncertainty (VT-3) or examined a textbook (VT-4). Global satisfaction was inversely and significantly correlated (r = -0.47) with the patients' perception of uncertainty in the physician. The manner in which clinical uncertainty is disclosed to patients and then resolved by the physician appears to affect patients' satisfaction.

Ambulatory Care↗
PubMedDate not supplied

Predicting the need for hospitalization of ambulatory patients with pneumonia.

OBJECTIVE: To develop clinical guidelines to identify patients with pneumonia who might be safely treated as outpatients. DESIGN: Retrospective chart review to derive guidelines, with subsequent prospective validation. SETTING: Initial review completed for patients seen in the emergency room (ER) of a university hospital and a community-based internal medicine practice. Validation conducted in the ERs of a university hospital and a community teaching hospital. PATIENTS/PARTICIPANTS: Individuals aged 16 years and older presenting with newly diagnosed pneumonia. Follow-up obtained through mail or telephone contact and chart review. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the initial retrospective review, 141 pneumonia patients without obvious reasons for hospital admission were identified and then classified as hospitalization necessary or unnecessary. Of these patients, 33 were classified as requiring admission. Multivariate analysis identified five variables that differentiated low-risk from high-risk study patients. These variables (and their relative weights) were: serious comorbid illness (3 points); preexisting lung disease (2 points); multilobar lung involvement by the disease by chest x-ray (2 points); observed or likely aspiration (2 points); and symptom duration of less than 7 or greater than 28 days (1 point). Risk scores were calculated using these variables. Patients with low scores (0-2 points) rarely had complications, and only one of 53 such patients (2%) was judged to require hospitalization. In contrast, patients with high scores (greater than or equal to 6 points) had frequent complications and 20 of 29 (69%) were felt to need hospitalization. Similar results were found during the validation phase. CONCLUSIONS: Clinical findings appear to help distinguish patients who need admission for treatment of pneumonia from those who do not. If validated in other settings, the clinical utility of these guidelines in assisting decision making about hospitalization should be determined.

Adolescent↗
PubMedDate not supplied

Reducing unnecessary coronary care unit admissions: a comparison of three decision aids.

OBJECTIVE: To determine whether published decision rules for ischemic heart disease have practical value in reducing unnecessary admissions to coronary care units. DESIGN: Prospective cohort study. SETTING: A community hospital emergency room. PATIENTS: 235 consecutive patients presenting to an emergency room with a chief complaint of chest pain. MEASUREMENTS: Clinical information, including observations needed to use previously published decision aids, was collected on special forms at the time of the emergency room visit. Follow-up information was obtained from the medical records of patients who were admitted and by telephone interviews with patients who were discharged. The authors compared the residents' actual decisions with the predictions of the decision aids regarding their ability to predict complications (that is, to identify patients who needed admission or intensive care). MAIN RESULTS AND CONCLUSIONS: None of the decision aids could reduce unnecessary admissions without seriously increasing the rate of inappropriate discharges. However, within the clinically relevant subgroup of patients for whom the decision to admit or discharge was not obvious on clinical grounds (those without complications on presentation whom the residents chose not to discharge), the decision aids examined, used in combination to verify the need for admission, might have safely averted some unnecessary admissions.

Clinical Protocols↗
PubMedDate not supplied

Workup bias in prediction research.

Studies often suggest that accepted clinical predictors actually have little predictive strength. One explanation for some such results is the presence of workup bias. To explore the effects of workup bias in prediction research, the authors modeled the effects of workup bias on the ability of early clinical findings to predict intracerebral hemorrhage in patients with stroke. In a simulated biased sample, workup bias resulted in distorted operating characteristics for those clinical findings influencing application of the "gold standard" and for other related findings. Sensitivity was increased, but both specificity and likelihood ratios were decreased in the biased sample. Workup bias can spuriously decrease predictive abilities for accepted clinical findings when such findings guide application of the "gold standard." Investigators should be aware of the potential effects of workup bias, search for clues to its occurrence, and interpret study results carefully when it is present.

Adult↗