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Biomedical subjects

W Levinson

Publications and source records attributed to W Levinson.

At least 127 records · Page 7Linked to original sources
PubMedDate not supplied

Informed decision making in outpatient practice: time to get back to basics.

CONTEXT: Many clinicians have called for an increased emphasis on the patient's role in clinical decision making. However, little is known about the extent to which physicians foster patient involvement in decision making, particularly in routine office practice. OBJECTIVE: To characterize the nature and completeness of informed decision making in routine office visits of both primary care physicians and surgeons. DESIGN: Cross-sectional descriptive evaluation of audiotaped office visits during 1993. SETTING AND PARTICIPANTS: A total of 1057 encounters among 59 primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons; 2 to 12 patients were recruited from each physician's community-based private office. MAIN OUTCOME MEASURES: Analysis of audiotaped patient-physician discussions for elements of informed decision making, using criteria that varied with the level of decision complexity: basic (eg, laboratory test), intermediate (eg, new medication), or complex (eg, procedure). Criteria for basic decisions included discussion of the nature of the decision and asking the patient to voice a preference; other categories had criteria that were progressively more stringent. RESULTS: The 1057 audiotaped encounters contained 3552 clinical decisions. Overall, 9.0% of decisions met our definition of completeness for informed decision making. Basic decisions were most often completely informed (17.2%), while no intermediate decisions were completely informed, and only 1 (0.5%) complex decision was completely informed. Among the elements of informed decision making, discussion of the nature of the intervention occurred most frequently (71 %) and assessment of patient understanding least frequently (1.5%). CONCLUSIONS: Informed decision making among this group of primary care physicians and surgeons was often incomplete. This deficit was present even when criteria for informed decision making were tailored to expect less extensive discussion for decisions of lower complexity. These findings signal the need for efforts to encourage informed decision making in clinical practice.

Colorado↗
PubMedDate not supplied

A study of patient clues and physician responses in primary care and surgical settings.

CONTEXT: Patients often present clues (direct or indirect comments about personal aspects of their lives or their emotions) during conversations with their physicians. These clues represent opportunities for physicians to demonstrate understanding and empathy and thus, to deepen the therapeutic alliance that is at the heart of clinical care. A paucity of information exists regarding how physicians address the psychological and social concerns of patients. OBJECTIVES: To assess how patients present clues and how physicians respond to these clues in routine primary care and surgical settings. DESIGN, SETTING, AND PARTICIPANTS: Descriptive, qualitative study of 116 randomly selected routine office visits to 54 primary care physicians and 62 surgeons in community-based practices in Oregon and Colorado, audiotaped and transcribed in 1994. MAIN OUTCOME MEASURES: Frequency of presentation of clues by patients during office visits, nature (emotional vs social) and content of clues, and nature of physician responses to clues, coded as positive or missed opportunity. RESULTS: Fifty-two percent and 53% of the visits in primary care and surgery, respectively, included 1 or more clues. During visits with clues, the mean number of clues per visit was 2.6 in primary care and 1.9 in surgery. Patients initiated approximately 70% of clues, and physicians initiated 30%. Seventy-six percent of patient-initiated clues in primary care settings and 60% in surgical settings were emotional in nature. In surgery, 70% of emotional clues related to patients' feelings about their biomedical condition, while in primary care, emotional clues more often related to psychological or social concerns (80%) in patients' lives. Physicians responded positively to patient emotions in 38% of cases in surgery and 21% in primary care, but more frequently they missed opportunities to adequately acknowledge patients' feelings. Visits with missed opportunities tended to be longer than visits with a positive response. CONCLUSION: This study suggests that physicians in both primary care and surgery can improve their ability to respond to patient clues even in the context of their busy clinical practices. JAMA. 2000;284:1021-1027

Communication↗
PubMedDate not supplied

The heart of darkness: the impact of perceived mistakes on physicians.

OBJECTIVES: To describe how physicians think and feel about their perceived mistakes, to examine how physicians' prior beliefs and manners of coping with mistakes may influence their emotional responses, and to promote further discussion in the medical community about this sensitive issue. DESIGN: Audiotaped, in-depth interviews with physicians in which each physician discussed a previous mistake and its impact on his or her life. Transcripts of the interviews were analyzed qualitatively and the data organized into five topic areas: the nature of the mistake, the physician's beliefs about the mistake, the emotions experienced in the aftermath of the mistake, the physician's way of coping with the mistake, and changes in the physician's practice as a result of the mistake. PARTICIPANTS AND SETTING: Eleven general internists and medical subspecialists practicing at a community, university-affiliated hospital in Oregon. RESULTS: Themes emerging from analysis of the interviews were the ubiquity of mistakes in clinical practice; the infrequency of self-disclosure about mistakes to colleagues, family, and friends; the lack of support among colleagues; the degree of emotional impact on the physician, so that some mistakes were remembered in great detail even after several years; and the influence of the physician's professional locus of control on subsequent emotions. CONCLUSIONS: The perception of having made a mistake creates significant emotional distress for practicing physicians. The severity of this distress may be influenced by factors such as prior beliefs and perfectionism. The extent to which physicians share this distress with colleagues may be influenced by the degree of competitiveness engendered by medical training. Open discussion of mistakes should be more prominent in medical training and practice, and there should be continued research on this topic.

Clinical Competence↗
PubMedDate not supplied

Sex and the teacher--learner relationship in medicine.

As the numbers of women medical students, residents, and faculty increase, sexuality in teacher-learner relationships will present challenges for individuals and institutions. Ethical and legal guidelines regarding sexual harassment and contact already exist for many medical schools, hospitals, and professional organizations, as well as state and federal law. Individuals and institutions can begin to address these issues through policy development and educational sessions addressing human sexuality, communication skills, and the process of becoming a physician.

Adult↗
PubMedDate not supplied

Parasitic infections in asymptomatic homosexual men: cost-effective screening.

The purpose of this study was to develop a cost-effective strategy for screening for enteric protozoan infections in homosexual men without gastrointestinal symptoms suggesting infection. One hundred and one homosexual men in Portland, Oregon, each submitted at least one unpurged stool sample; 91% submitted three samples each. Of these, 27% had Entamoeba histolytica, 61% had nonpathogenic protozoa with or without E. histolytica, 36% had a nonpathogen alone, and 3% had Giardia lamblia. Protozoan infection was highly associated with the practice of anilingus (p less than 0.005). Infection with E. histolytica correlated significantly with the presence of nonpathogenic protozoa (p less than 0.005). The following screening strategy was judged to be the most cost-effective: examine one sample first; if E. histolytica is found or if the sample is negative, no further investigation is required; if a nonpathogen is found, one additional sample should be obtained. This strategy had a sensitivity for E. histolytica of 85% and a cost of $136 per case detected.

Adult↗
PubMedDate not supplied

The effect of resident involvement on community hospital charges.

Attempts to explain the high cost of care in teaching hospitals have yielded conflicting results. This study was conducted to compare hospital charges and lengths of stay for two groups of patients: one cared for by a resident team and the other cared for by attending physicians. The study was conducted at a university-affiliated hospital in Portland, Oregon. An initial group of 5,451 admissions was examined, considering type of doctor (resident or attending), severity of illness, and patient demographic characteristics. A regression analysis revealed that total charges were similar in the two groups, but only 14% of the variance in log total charges was explained. A subgroup of 1,058 admissions in the eight most common diagnosis-related groups (DRGs) was further evaluated. In this analysis total charges for the resident patient group were 52% higher than charges for the patient group cared for by attending physicians. Forty-one per cent of the variance was explained, with type of doctor and severity of illness accounting for 5% and 10%, respectively. Further examination of one DRG indicated that additional factors not included in previous studies, such as extent of preadmission evaluation, ethical factors influencing treatment options, and patient expectations for care, may be important determinants of hospital charges. This study demonstrates that the high cost of resident care is not fully explained by currently available measures.

Diagnosis-Related Groups↗
PubMedDate not supplied

In context: physician-patient communication and managed care.

Communication between a physician and his or her patient is a critical component of medical care delivery. The quality of communication affects patient satisfaction and health outcomes. Managed care has heightened the awareness of communication because of the direct links among communication, outcomes, and malpractice liability. This article describes patient satisfaction, the relationship between communication and biological outcomes, the role that communication plays in malpractice prevention, the communication challenges present in the managed health care environment, and the need for communication skills training.

Communication↗
PubMedDate not supplied

Women in academic medicine: strategies for balancing career and personal life.

We conducted a national survey to explore how women in academic medicine balance career and family responsibilities. A questionnaire was mailed to all women 50 years of age and under who held full-time appointments in departments of medicine (N = 862) as listed in the faculty roster of the Association of American Medical Colleges. This paper describes the types of coping strategies the respondents use to balance career and personal life. Seventy-seven percent of respondents (430) reported at least one coping strategy. The 1,117 strategies were grouped into 4 general categories: changing structural aspects of their lives, increasing efficiency, limiting personal expectations, and social support. Illustrative examples of each of the categories and their subcategories are provided. In addition, the association between respondent demographics and coping methods is examined. This study describes the diverse and creative methods women faculty use to balance career and personal lives. We believe that sharing the coping strategies of these respondents will be helpful to other physicians who face similar challenges in their lives and to women medical students planning careers in academic medicine.

Adaptation, Psychological↗