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Susan D Block

Publications and source records attributed to Susan D Block.

At least 19 recordsLinked to original sources
PubMed2006

Mutuality and specificity of mental disorders in advanced cancer patients and caregivers.

BACKGROUND: We sought to determine mutuality and specificity in rates of mental disorders between advanced cancer patients and their caregivers. METHOD: Data from 168 non-genetically related patient-caregiver dyads participating in the multi-site Coping with Cancer (CWC) study were included in this analysis. Multivariate logistic regression analyses were conducted to examine associations between diagnoses of a psychiatric disorder in patients with diagnoses of psychiatric disorders in caregivers, and vice versa, controlling for confounders. RESULTS: When patients met criteria for any psychiatric diagnosis, then caregivers were 7.9 times (P < 0.0001) more likely to meet criteria for any psychiatric diagnosis, and vice versa. Caregiver Panic Disorder (PD) diagnosis was associated with patient Generalized Anxiety Disorder (GAD). Patient GAD was also associated with caregiver PD. Finally, patient PD was associated with caregiver GAD and caregiver Post-Traumatic Stress Disorder (PTSD). CONCLUSIONS: To our knowledge, this is the first study that demonstrates the mutuality of psychiatric disorders in both advanced cancer patients and their informal caregivers. Specifically, the presence of anxiety disorders in one partner (either caregiver or patient) was associated with a greater likelihood of anxiety disorders in the other. Results suggest that psychiatric distress should be assessed in both patients and their caregivers, and that mental illness in one should raise concern about the possibility of a psychiatric disorder in the other. Results also suggest that targeted interventions to address shared fears and concerns of patients and caregivers might reduce anxiety in the end phases of the patient's illness.

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PubMed2006

Peaceful awareness in patients with advanced cancer.

BACKGROUND: Previous studies have shown that prognostic awareness may be harmful to mental health yet beneficial for end of life care planning. The effects of prognostic awareness coupled with a sense of inner peace are unknown. METHODS: In the multisite, longitudinal Coping with Cancer Study, 280 patients with advanced cancer were interviewed at baseline. Patients defining themselves as "terminally ill" and/or "at peace" most days were paired with others on sociodemographic, mental health and advance care planning. Primary caregivers of deceased patients were interviewed 6 months postloss and compared on their physical and mental health and their perceptions of patients' end-of-life care and death. RESULTS: Overall, 17.5% of patients reported being both peaceful and aware. Peacefully aware patients had lower rates of psychological distress and higher rates of advance care planning (e.g., completing do-not-resuscitate [DNR] orders, advance care planning discussions with physicians) than those who were not peacefully aware. Additionally, peacefully aware patients had the highest overall quality of death as reported by their caretakers in a postmortem evaluation. Surviving caregivers of peacefully aware patients were more physically and mentally healthy 6 months postloss than caregivers of patients who were "aware" but not peaceful. CONCLUSIONS: Patients with advanced cancer who are peacefully aware have better mental health and quality of death outcomes, and their surviving caregivers have better bereavement outcomes. Peaceful awareness is associated with modifiable aspects of medical care (e.g., discussions about terminal treatment preferences).

Adaptation, Psychological↗
PubMed2006

Psychological issues in end-of-life care.

This paper provides a systematic, evidence-based review of the psychological issues confronted by patients at the end of life, drawing on recent literature. The epidemiology, approach to clinical assessment, clinical presentation, and therapeutic options related to common psychological issues that arise in end-stage illness are described. The spectrum of normal and dysfunctional reactions are identified, and approaches to enhancing coping and quality of life are emphasized. The learner will be able to describe: (1) normal coping responses of patients at the end of life; (2) epidemiology of common psychiatric disorders at the end of life; (3) the approach to clinical assessment of psychological distress at the end of life; and (4) therapeutic approaches to common psychological problems at the end of life.

Adaptation, Psychological↗
PubMed2006

Creating enduring change: demonstrating the long-term impact of a faculty development program in palliative care.

BACKGROUND: Improved educational and evaluation methods are needed in continuing professional development programs. OBJECTIVE: To evaluate the long-term impact of a faculty development program in palliative care education and practice. DESIGN: Longitudinal self-report surveys administered from April 2000 to April 2005. PARTICIPANTS: Physician and nurse educators from North America and Europe. All program graduates (n = 156) were invited to participate. INTERVENTION: Two-week program offered annually (2000 to 2003) with 2 on-site sessions and 6-month distance-learning period. Learner-centered training addressed teaching methods, clinical skill development, and organizational and professional development. MEASURES: Self-administered survey items assessing behaviors and attitudes related to palliative care teaching, clinical care, and organizational and professional development at pre-, postprogram, and long-term (6, 12, or 18 months) follow-up. RESULTS: Response rates: 96% (n = 149) preprogram, 73% (n = 114) follow-up. Participants reported increases in: time spent in palliative care practice (38% preprogram, 47% follow-up, P < .01); use of learner-centered teaching approaches (sum of 8 approaches used "a lot": preprogram 0.7 +/- 1.1, follow-up 3.1 +/- 2.0, P < .0001); and palliative care topics taught (sum of 11 topics taught "a lot": preprogram 1.6 +/- 2.0, follow-up 4.9 +/- 2.9, P < .0001). Reported clinical practices in psychosocial dimensions of care improved (e.g., assessed psychosocial needs of patient who most recently died: 68% preprogram, 85% follow-up, P = .01). Nearly all (90%) reported launching palliative care initiatives, and attributed their success to program participation. Respondents reported major improvements in confidence, commitment to palliative care, and enthusiasm for teaching. Eighty-two percent reported the experience as "transformative." CONCLUSIONS: This evidence of enduring change provides support for the potential of this educational model to have measurable impact on practices and professional development of physician and nurse educators.

Chi-Square Distribution↗
PubMed2005

Psychiatric disorders and mental health service use in patients with advanced cancer: a report from the coping with cancer study.

BACKGROUND: Psychological morbidity has been proposed as a source of distress in cancer patients. This study aimed to: 1) determine the prevalence of diagnosable psychiatric illnesses, and 2) describe the mental health services received and predictors of service utilization in patients with advanced cancer. METHODS: This was a cross-sectional, multi-institutional study of 251 eligible patients with advanced cancer. Eligibility included: distant metastases, primary therapy failure, nonpaid caregiver, age > or =20 years, stamina for the interview, English or Spanish-speaking, and adequate cognitive ability. Trained interviewers administered the Structured Clinical Interview for the Diagnostic Statistical Manual IV (DSM-IV) modules for Major Depressive Disorder, Generalized Anxiety Disorder, Panic Disorder, Post-Traumatic Stress Disorder, and a detailed questionnaire regarding mental health service utilization. RESULTS: Overall, 12% met criteria for a major psychiatric condition and 28% had accessed a mental health intervention for a psychiatric illness since the cancer diagnosis. Seventeen percent had discussions with a mental health professional; 90% were willing to receive treatment for emotional problems. Mental health services were not accessed by 55% of patients with major psychiatric disorders. Cancer patients who had discussed psychological concerns with mental health staff (odds ratio [OR] = 19.2; 95% confidence interval [95% CI], 8.90-41.50) and non-Hispanic white patients (OR = 2.7; 95% CI, 1.01-7.43) were more likely to receive mental health services in adjusted analysis. CONCLUSIONS: Advanced cancer patients experience major psychiatric disorders at a prevalence similar to the general population, but affected individuals have a low rate of utilizing mental health services. Oncology providers can enhance utilization of mental health services, and potentially improve clinical outcomes, by discussing mental health concerns with their patients.

Adaptation, Psychological↗
PubMed2005

Evaluating claims-based indicators of the intensity of end-of-life cancer care.

OBJECTIVE: To evaluate measures that could use existing administrative data to assess the intensity of end-of-life cancer care. METHODS: Benchmarking standards and statistical variation were evaluated using Medicare claims of 48,906 patients who died from cancer from 1991 through 1996 in 11 regions of the United States. We assessed accuracy by comparing administrative data to 150 medical records in one hospital and affiliated cancer treatment center. RESULTS: Systems not providing overly aggressive care near the end of life would be ones in which less than 10% of patients receive chemotherapy in the last 14 days of life, less than 2% start a new chemotherapy regimen in the last 30 days of life, less than 4% have multiple hospitalizations or emergency room visits or are admitted to the intensive care unit (ICU) in the last month of life, and less than 17% die in an acute care institution. At least 55% of patients would receive hospice services before death from cancer, and less than 8% of those would be admitted to hospice within only 3 days of death. All measures were found to have accuracy ranging from 85 to 97% and 2- to 5-fold adjusted variability between the 5th and 95th percentiles of performance. CONCLUSIONS: The usefulness of these measures will depend on whether the concept of intensity of care near death can be further validated as an acceptable and important quality issue among patients, their families, health care providers, and other stakeholders in oncology.

Drug Utilization↗
PubMed2005

Questioning care at the end of life.

BACKGROUND: The goal of the larger study was to explore physicians' emotional responses to the death of their patients; this study analyzed a subset of physician transcripts to elucidate the construct of questioning care, which emerged from the larger study. OBJECTIVE: To analyzes how physicians question care-expressing concern, unease, or uncertainty about treatment decisions and practices, errors, or adverse events-as they attend dying patients. DESIGN: Retrospective interview study of physicians caring for randomly selected deaths on the medical service of a major academic teaching hospital, using qualitative and quantitative measures. SETTING, SUBJECTS: 188 attendings, residents, and interns on the internal medical services of two academic medical centers were part of the larger study. A subsample of 75 physician narratives was selected for qualitative data analysis for this study. MEASUREMENTS: Qualitative measures included open-ended questions eliciting physicians' stories of the most recent and a most emotionally powerful patient death they have experienced. Grounded theory was used to analyze physician narratives. Quantitative instruments measured physician attitudes toward end-of-life care and responses to the most recent and most emotional patient death. RESULTS: Physicians question care more frequently in most emotional deaths (42%) than in most recent deaths (34%). Physicians question communication with patients and families and within medical teams, medical judgment and technique, standards of practice, and high-risk treatments, often assigning responsibility for medical management they perceive as inappropriate, futile, overly aggressive, or mistakes in judgment and technique. Responsibility ranges from the distal (the culture of medicine) to the proximal (personal). Frustration, guilt, and anger are more frequently expressed in these narratives when care is questioned. CONCLUSIONS: A typology of questioning care emerged from these physicians' narratives that parallels and reflects recent and classic research on medical error and the culture of medicine. Physicians' questions about care can contribute to designing training experiences for residents and to improving the quality of systems that affect patients' experiences at life's end and physicians' experiences in caring for dying patients.

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PubMed2005

"This is just too awful; I just can't believe I experienced that...": medical students' reactions to their "most memorable" patient death.

PURPOSE: To examine medical students' emotional reactions to their "most memorable" patient death and the support they receive. METHOD: In 2000-01, 65 third-year medical students at two Northeastern U.S. medical schools were randomly selected to participate in 60-90-minute interviews of open-ended and structured questions and a written questionnaire (using a ten-point scale) about their "most memorable" patient death. Independent reviewers coded each interview to identify the analytical categories. Descriptive data were generated from the written questionnaire. RESULTS: A total of 32 interviews were used in the analysis. Twelve (38%) students were in contact with the patient for less than 24 hours and 23 (73%) were not at all or minimally close to the patient (0-3 on ten-point scale). Sixteen of 28 students (57%) rated the impact of the death as highly emotionally powerful (7-10 on ten-point scale). The finality of deaths, particularly sudden deaths, evoked strong emotions. Four of 16 (25%) students who found the death highly emotionally powerful rated the amount of support from supervisors as extremely inadequate (0-3 on ten-point scale). There was no discussion of the death in 17 (63%) of the 27 cases in which the patient was cared for by the student's team. Students perceived from supervising physicians that death and emotions are negative aspects of medicine. CONCLUSIONS: Medical students experienced patient deaths as emotionally powerful even when they were not close to the patients. Debriefing sessions with students were rare, and many students felt inadequately supported. Thus, a unique opportunity to teach about death, emotions and coping with stress is often lost.

Adaptation, Psychological↗
PubMed2005

"It was haunting...": physicians' descriptions of emotionally powerful patient deaths.

PURPOSE: To understand the emotional experiences of physicians who care for dying patients and to identify educational opportunities for improving patient care and physician well-being. METHOD: Between 1999-2001, physicians at two quaternary care medical centers in Boston, Massachusetts, and Pittsburgh, Pennsylvania, participated in 90-minute, semistructured personal interviews on their most emotionally powerful patient death. Quantitative data was obtained through face-to-face surveys rated on ten-point scales that asked physicians about emotional characteristics of and emotional responses to the death. In the qualitative portion of the survey, physicians were asked to describe the details of the most emotionally powerful patient death, the types and sequence of their emotional reactions, their methods of coping, and subsequent changes in behavior. RESULTS: Physicians had powerful experiences with death during all stages of their careers. Experiences with patient death generally fit into one of three types: "good," "overtreated," or "shocking/unexpected." Housestaff often described coping in isolation with the disturbing emotions generated in the care of dying patients. Physicians learned how to care for and cope with dying patients from their experiences with patients whose deaths were most emotionally powerful and reported changes in their clinical behavior and career paths as a result. CONCLUSIONS: Physicians' emotional reactions to patient death can affect patient care and the personal lives of physicians. Supervising physicians have an opportunity to improve both the care of dying patients and house-staff coping with these deaths by using the "teachable moments" that are present for trainees as they care for the dying.

Adaptation, Psychological↗
PubMed2005

Teaching and learning end-of-life care: evaluation of a faculty development program in palliative care.

PURPOSE: To evaluate the effectiveness of the Program in Palliative Care Education and Practice (PCEP), an intensive faculty development program at Harvard Medical School. METHOD: PCEP is a two-week program offered annually with two on-site sessions in Boston, MA, and an interim period distance-learning component. Training integrates palliative care clinical skill development, learning theory and teaching methods, and leadership and organizational change. Longitudinal surveys (preprogram, retrospective preprogram, and postprogram) of participants from 2000-03 assessed self-reported preparation in providing and teaching palliative care; teaching and patient care practices; and satisfaction with program. RESULTS: The response rate was 96% (n=149) for Session I and 72% for both Session I and II (n=113). Questionnaire responses demonstrated statistically significant improvements with large effect sizes (range 0.7-1.8) on nearly all measures. Preparation increased from 3.0+/-1.1 to 4.2+/-0.7 for providing end-of-life care (1=not well prepared, 5=very well prepared), and from 2.6+/-1.0 to 4.3+/-0.7 for teaching this topic. Respondents reported behavioral changes in patient care and teaching; e.g., after the program, 63% noted that, specifically as a result of attending the course, they encouraged learners to reflect on their emotional responses to dying patients, and 57% conducted experiential exercises (e.g., role-play). Eighty-two percent rated the experience as "transformative," and many responses to open-ended items described powerful learning experiences. Participants rated the program highly (4.9+/-0.1, 1=lowest, 5=highest rating). CONCLUSIONS: Integrating clinical content with learning about educational methods is an efficient and effective approach to enhancing clinical faculty's capacity to model and teach clinical care. This program offers an educational model that engages practitioners, stimulates changes in practice, and offers opportunities for reflection and professional revitalization.

Academic Medical Centers↗
PubMed2005

There is hope for the future: national survey results reveal that geriatric medicine fellows are well-educated in end-of-life care.

OBJECTIVES: To assess the status of geriatric medicine (GM) fellows' training experiences in end-of-life care via self-report. DESIGN: Anonymous surveys completed by mail, Web access, and telephone. SETTING: U.S. accredited GM fellowship training programs. PARTICIPANTS: Two hundred ninety-six surveys were sent to graduating GM fellows in 1- and 2-year programs across the Unites States. MEASUREMENTS: Measurements assessed self-reported attitudes, quantity and quality of end-of-life care education, preparation to provide care, and perceived value of caring for dying patients. RESULTS: Response rate was 74%. Ninety-five percent or more of respondents held positive views about physicians' responsibility and ability to help dying patients. Seventy percent of fellows had completed a rotation focused on end-of-life care. Fellows who had done such rotations rated their end-of-life care education as highly as their overall geriatrics training. Fellows frequently received teaching in many end-of-life care topics, with lower rates of teaching how to say goodbye and responding to requests for assisted suicide. Overall, fellows felt well prepared to care for dying patients. Four factors independently predicted such preparedness: having had a palliative or end-of-life care rotation, being female, having been taught how to say goodbye to patients, and perceiving that it is important to attending physicians that fellows learn to care for dying patients. CONCLUSION: GM fellows feel their end-of-life care education is excellent and feel prepared to take care of dying patients. It is critical that geriatricians in training have access to and take advantage of palliative and end-of-life care rotations.

Adult↗
PubMed2004

Trends in the aggressiveness of cancer care near the end of life.

PURPOSE: To characterize the aggressiveness of end-of-life cancer treatment for older adults on Medicare, and its relationship to the availability of healthcare resources. PATIENTS AND METHODS: We analyzed Medicare claims of 28,777 patients 65 years and older who died within 1 year of a diagnosis of lung, breast, colorectal, or other gastrointestinal cancer between 1993 and 1996 while living in one of 11 US regions monitored by the Surveillance, Epidemiology, and End Results Program. RESULTS: Rates of treatment with chemotherapy increased from 27.9% in 1993 to 29.5% in 1996 (P =.02). Among those who received chemotherapy, 15.7% were still receiving treatment within 2 weeks of death, increasing from 13.8% in 1993 to 18.5% in 1996 (P <.001). From 1993 to 1996, increasing proportions of patients had more than one emergency department visit (7.2% v 9.2%; P <.001), hospitalization (7.8% v 9.1%; P =.008), or were admitted to an intensive care unit (7.1% v 9.4%; P =.009) in the last month of life. Although fewer patients died in acute-care hospitals (32.9% v 29.5%; P <.001) and more used hospice services (28.3% v 38.8%; P <.001), an increasing proportion of patients who received hospice care initiated this service only within the last 3 days of life (14.3% v 17.0%; P =.004). Black patients were more likely than white patients to experience aggressive intervention in nonteaching hospitals but not in teaching hospitals. Greater local availability of hospices was associated with less aggressive treatment near death on multivariate analysis. CONCLUSION: The treatment of cancer patients near death is becoming increasingly aggressive over time.

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PubMed2004

Narrative nuances on good and bad deaths: internists' tales from high-technology work places.

Public and professional discourses in American society about what constitutes a "good death" have flourished in recent decades, as illustrated by the pivotal SUPPORT study and the growing palliative care movement. This paper examines a distinctive medical discourse from high-technology academic medical centers through an analysis of how physicians who are specialists in internal medicine tell stories about the deaths of patients in their care. 163 physicians from two major academic medical centers in the United States completed both qualitative open interviews and quantitative attitudinal measures on a recent death and on the most emotionally powerful death they experienced in the course of their careers. A subsample of 75 physicians is the primary source for the qualitative analysis, utilizing Atlas-ti."Good death" and "bad death" are common in popular discourse on death and dying. However, these terms are rarely used by physicians in this study when discussing specific patients and individual deaths. Rather, physicians' narratives are nuanced with professional judgments about what constitutes quality end-of-life care. Three major themes emerge from these narratives and frame the positive and negative characteristics of patient death. Time and Process: whether death was expected or unexpected, peaceful, chaotic or prolonged; Medical Care and Treatment Decisions: whether end-of-life care was rational and appropriate, facilitating a "peaceful" or "gentle" death, or futile and overly aggressive, fraught with irrational decisions or adverse events; Communication and Negotiation: whether communication with patients, family and medical teams was effective, leading to satisfying management of end-of-life care, or characterized by misunderstandings and conflict. When these physicians' narratives about patient deaths are compared with the classic sociological observations made by Glaser and Strauss in their study A Time for Dying (1968), historical continuities are evident as are striking differences associated with rapid innovation in medical technologies and a new language of medical futility. This project is part of a broader effort in American medicine to understand and improve end-of-life care.

Academic Medical Centers↗
PubMed2004

End-of-life care in the curriculum: a national study of medical education deans.

PURPOSE: To describe attitudes and practices of end-of-life care teaching in the undergraduate medical curriculum in the United States as reported by administrative leadership and identify opportunities for improvement. METHOD: A telephone survey of associate deans for medical education or curricular affairs at a random sample of 62 accredited U.S. medical schools was conducted in 2002. RESULTS: Fifty-one deans participated (82% response rate). Most (84%) described end-of-life care education as "very important" and supported incorporating more end-of-life care teaching into the undergraduate curriculum. Sixty-seven percent reported that insufficient time is currently given to palliative care in their curriculum. Although a majority opposed required courses (59%) or clerkships (70%) that focused on end-of-life care, they did unanimously endorse integrating teaching end-of-life care into existing courses or clerkships. Key barriers to incorporating more end-of-life care into the curriculum included lack of time in the curriculum, lack of faculty expertise, and absence of a faculty leader. CONCLUSION: Associate deans for medical education or curricular affairs in the United States support integrating end-of-life care content into existing courses and clerkships throughout the undergraduate medical curriculum. Successful integration will require institutional investment in faculty development, including both the development of faculty leaders to drive change efforts, and the education of all faculty who teach students and exert influence as role models and mentors. The strong support for end-of-life care education expressed by academic leaders in this study, combined with the high level of interest expressed in the authors' 2001 national survey of students, provide evidence of the potential for meaningful change in the undergraduate medical curriculum.

Adult↗
PubMed2003

Doctors' emotional reactions to recent death of a patient: cross sectional study of hospital doctors.

OBJECTIVES: To describe doctors' emotional reactions to the recent death of an "average" patient and to explore the effects of level of training on doctors' reactions. DESIGN: Cross sectional study using quantitative and qualitative data. SETTING: Two academic teaching hospitals in the United States. PARTICIPANTS: 188 doctors (attending physicians (equivalent to UK consultants), residents (equivalent to UK senior house officers), and interns (equivalent to UK junior house officers)) who cared for 68 patients who died in the hospital. MAIN OUTCOME MEASURES: Doctors' experiences in providing care, their emotional reactions to the patient's death, and their use of coping and social resources to manage their emotions. RESULTS: Most doctors (139/188, 74%) reported satisfying experiences in caring for a dying patient. Doctors reported moderate levels of emotional impact (mean 4.7 (SD 2.4) on a 0-10 scale) from the death. Women and those doctors who had cared for the patient for a longer time experienced stronger emotional reactions. Level of training was not related to emotional reactions, but interns reported needing significantly more emotional support than attending physicians. Although most junior doctors discussed the patient's death with an attending physician, less than a quarter of interns and residents found senior teaching staff (attending physicians) to be the most helpful source of support. CONCLUSIONS: Doctors who spend a longer time caring for their patients get to know them better but this also makes them more vulnerable to feelings of loss when these patients die. Medical teams may benefit from debriefing within the department to give junior doctors an opportunity to share emotional responses and reflect on the patient's death.

Adaptation, Psychological↗
PubMed2003

The need for end-of-life care training in nephrology: national survey results of nephrology fellows.

Because of the high mortality rate of end-stage renal disease, nephrologists care for many dying patients. However, the education of nephrology fellows in palliative care has not been assessed. We surveyed second-year nephrology fellows to assess the quantity and quality of teaching they received in palliative medicine and also asked about their preparedness to manage patients at the end of life. A 63% survey response rate yielded 173 surveys for evaluation. Nearly all fellows (99%) agreed that physicians have a responsibility to help patients at the end of life; half thought it was very important to learn how to care for dying patients. On a 10-point scale in which 0 is no teaching and 10 is a lot of teaching, fellows reported significantly less teaching in end-of-life care (mean score, 3.8 +/- 2.6) than in managing a patient with distal renal tubular acidosis (mean score, 6.3 +/- 2.5) or on hemodialysis therapy (mean score, 8.9 +/- 1.5; all P < 0.0001). Specific palliative care content areas were taught infrequently; only 22% of fellows were taught how to tell a patient he or she is dying. Fellows who had contact with a palliative care specialist reported more education on end-of-life issues and believed they were better prepared to provide such care. Fellows' palliative care experiences during fellowship frequently occurred without attending nephrologist supervision; 32% of fellows had conducted 2 or fewer family meetings, and 26% of all family meetings occurred without an attending nephrologist. Fellows believed they were best prepared to manage a patient on hemodialysis therapy (mean score, 8.9 +/- 1) and least prepared to manage a patient at the end of life (mean score, 6.1 +/- 2; P < 0.0001). Our results show that most nephrology fellows believe they should learn how to care for dying patients, but most fellowship programs do not offer this training. Our study therefore suggests that training in palliative care be incorporated into fellowship program curricula.

Data Collection↗
PubMed2003

Variation in predictors of primary care career choice by year and stage of training.

CONTEXT: It is not known whether factors associated with primary care career choice affect trainees differently at different times or stages of medical education. OBJECTIVE: To examine how role models, encouragement, and personal characteristics affect career choice at different stages (medical school vs residency) and periods (1994 vs 1997) of training. DESIGN: A split-panel design with 2 cross-sectional telephone surveys and a panel survey in 1994 and 1997. PARTICIPANTS: A national probability sample of fourth-year students (307 in 1994, 219 in 1997), 645 second-year residents in 1994, and 494 third-year residents in 1997. Of the fourth-year students interviewed in 1994, 241 (78.5%) were re-interviewed as third-year residents in 1997. MAIN OUTCOME MEASURE: Primary care (general internal medicine, general pediatrics, or family medicine) career choice. RESULTS: Having a primary care role model was a stronger predictor of primary care career choice for residents (odds ratio [OR], 18.0; 95% confidence interval [95% CI], 11.2 to 28.8 in 1994; OR, 43.7; 95% CI, 24.4 to 78.3 in 1997) than for students (OR, 6.5; 95% CI, 4.3 to 10.2; no variation by year). Likewise, peer encouragement was more predictive for residents (OR, 5.4; 95% CI, 3.3 to 8.9 in 1994; OR, 16.6; 95% CI; 9.7 to 28.4 in 1997) than for students (OR, 2.1; 95% CI, 1.3 to 3.2; no variation by year). Orientation to the emotional aspects of care was consistently associated with primary care career choice across stages and years of training. CONCLUSIONS: The effect of peer encouragement and role models on career choice differed for students and residents and, in the case of residents, by year of training, suggesting that interventions to increase the primary care workforce should be tailored to stage of training.

Adult↗