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Minji K Lee,1 Jennifer L St Sauver,1,2 Roger T Anderson,3 Mark Linzer,4 David T Eton1,2 1Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; 2Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; 3Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA; 4Hennepin Healthcare, Minneapolis, Minnesota, USA, University of Minnesota Medical School, Minneapolis, MN, USACorrespondence: Minji K LeeRobert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Harwick Building, Second Floor, 200 First St SW, Rochester, MN 55905, USATel +1 507 284 1310Email Lee.Minji@mayo.eduDavid T Eton Email eton.david@mayo.eduPurpose: To examine the factor structure and differential item functioning (DIF) of the Patient Experience with Treatment and Self-management (PETS version 2.0), a measure of treatment burden.Patients and Methods: Version 2.0 of the PETS has 60 items, extending the previously-validated 48-item version 1.0 by three domains (nine items) and three additional items in an existing domain. We conducted confirmatory factor analyses (CFA) on survey responses of 439 community-dwelling adults living with multiple chronic conditions who completed PETS version 2.0, using R packages, “lavaan” and “semTools.” We tested fit of second-order factors to explore simplifying the reporting of PETS scores. We examined DIF for the two second-order factors with “lordif” R package, testing groups by gender, education, and health literacy, using the McFadden pseudo R2 change criterion of ≥ 0.02 to flag items with DIF. Cronbach’s alpha and the intraclass correlation coefficient (ICC) were used to determine the reliability of PETS domains.Results: The first-order CFA model featuring 12 multi-item domains had an excellent fit (Comparative Fit Index [CFI]=0.989), as did the second-order CFA model (CFI=0.987), specifying two superordinate factors of treatment burden (workload and impact). Items in the workload and impact second-order factors did not show any DIF across gender, education, and health literacy groups as shown by McFadden pseudo R2 changes < 0.02. Cronbach’s alphas for all multi-item domain scales were ≥ 0.80, and ICCs of ten scales were ≥ 0.70, meeting the threshold for adequate test–retest reliability.Conclusion: Findings support the construct validity and reliability of PETS version 2.0. The fit of a factor model featuring superordinate (ie, second-order) factors of workload and impact supports index scoring that will simplify reporting of PETS scores. DIF analyses indicate that items from these indices can be interpreted in the same way, regardless of gender, education, or health literacy.Keywords: factor structure, patient-reported outcomes, multi-morbidity, psychometric testing, questionnaire, validation

Elizabeth A Rogers,1,2 Kathleen J Yost,3 Jordan K Rosedahl,3 Mark Linzer,4 Deborah H Boehm,5 Azra Thakur,5 Sara Poplau,5 Roger T Anderson,6 David T Eton3 1Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; 2Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA; 3Department of Health Services Research, Mayo Clinic, Rochester, MN, USA; 4Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; 5Minneapolis Medical Research Foundation, Minneapolis, MN, USA; 6University of Virginia School of Medicine, Charlottesville, VA, USA Aims: To validate a comprehensive general measure of treatment burden, the Patient Experience with Treatment and Self-Management (PETS), in people with diabetes. Methods: We conducted a secondary analysis of a cross-sectional survey study with 120 people diagnosed with type 1 or type 2 diabetes and at least one additional chronic illness. Surveys included established patient-reported outcome measures and a 48-item version of the PETS, a new measure comprised of multi-item scales assessing the burden of chronic illness treatment and self-care as it relates to nine domains: medical information, medications, medical appointments, monitoring health, interpersonal challenges, health care expenses, difficulty with health care services, role activity limitations, and physical/mental exhaustion from self-management. Internal reliability of PETS scales was determined using Cronbach’s alpha. Construct validity was determined through correlation of PETS scores with established measures (measures of chronic condition distress, medication satisfaction, self-efficacy, and global well-being), and known-groups validity through comparisons of PETS scores across clinically distinct groups. In an exploratory test of predictive validity, step-wise regressions were used to determine which PETS scales were most associated with outcomes of chronic condition distress, overall physical and mental health, and medication adherence. Results: Respondents were 37–88 years old, 59% female, 29% non-white, and 67% college-educated. PETS scales showed good reliability (Cronbach’s alphas ≥0.74). Higher PETS scale scores (greater treatment burden) were correlated with more chronic condition distress, less medication convenience, lower self-efficacy, and worse general physical and mental health. Participants less (versus more) adherent to medications and those with more (versus fewer) health care financial difficulties had higher mean PETS scores. Medication burden was the scale that was most consistently associated with well-being and patient-reported adherence. Conclusion: The PETS is a reliable and valid measure for assessing perceived treatment burden in people coping with diabetes. Keywords: treatment burden, patient-reported measure, measurement, patient perspective, disease management

David T Eton,1,2 Jennifer L Ridgeway,1,2 Mark Linzer,3 Deborah H Boehm,4 Elizabeth A Rogers,5 Kathleen J Yost,1,2 Lila J Finney Rutten,1,2 Jennifer L St Sauver,1,2 Sara Poplau,4 Roger T Anderson6 1Department of Health Sciences Research, 2Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 3Division of General Internal Medicine, Hennepin County Medical Center, 4Minneapolis Medical Research Foundation, 5Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, 6Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA Purpose: Having multiple chronic conditions (MCCs) can lead to appreciable treatment and self-management burden. Healthcare provider relational quality (HPRQ) – the communicative and interpersonal skill of the provider – may mitigate treatment burden and promote self-management. The objectives of this study were to 1) identify the associations between HPRQ, treatment burden, and psychosocial outcomes in adults with MCCs, and 2) determine if certain indicators of HPRQ are more strongly associated than others with these outcomes.Patients and methods: This is a cross-sectional survey study of 332 people with MCCs. Patients completed a 7-item measure of HPRQ and measures of treatment and self-management burden, chronic condition distress, self-efficacy, provider satisfaction, medication adherence, and physical and mental health. Associations between HPRQ, treatment burden, and psychosocial outcomes were determined using correlational analyses and independent samples t-tests, which were repeated in item-level analyses to explore which indicators of HPRQ were most strongly associated with the outcomes.Results: Most respondents (69%) were diagnosed with ≥3 chronic conditions. Better HPRQ was found to be associated with less treatment and self-management burden and better psychosocial outcomes (P

Background: PCEs are hypothesized to increase affinity for primary care careers. Subjects: Four focus groups (FGs) of randomly chosen medical students stratified by gender and year of medical school ( 40 students invited, 30 attended). Approximately 150 year I medical students surveyed by questionnaire. Design: Students were surveyed before and after year I (average response rate, 92%). FGs assessed year I students after the PCE and year 2 students without a PCE (controls). This pilot PCE included 14 half-days of "shadowing'' an office-based generalist during first semester. Analysis: FG transcripts were coded using a published model of career choice in Internal Medicine. Results: Among many positive comments (e.g., "wonderful role models", "'got me fired up about med school"), some unexpected themes emerged, including discomfort with patient relationships("direct patient contact was intimidating and a “tum off"), boredom ("Internal Medicine ... gotrepetitious", "peds was boring ... so many well-child exams") and primary care backlash ("too much push to primary care'). Learning climate comments were often negative in controls but less so in PCE students. When compared with men, women cared more about role conflict (work/home) issues, and made more positive comments about intellectual stimulation of the PCE. Survey results showed no change in interest in a primary care career after the PCE (44% interested before vs 46% after, P = 0.09). Conclusions: A PCE can have positive and negative influences on career choice. These influences may differ by gender. Students could gain a greater affinity for generalism by better preparation for interacting with patients, careful selection of preceptors, and less pressure to enter primary care.

David T Eton,1,2 Jennifer L Ridgeway,1,2 Jason S Egginton,1,2 Kristina Tiedje,3 Mark Linzer,4,5 Deborah H Boehm,4 Sara Poplau,6 Djenane Ramalho de Oliveira,7 Laura Odell,8 Victor M Montori,1,9 Carl R May,10 Roger T Anderson11 1Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; 2Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; 3Department of Sociology and Anthropology, Université Lumière Lyon 2, Lyon, France; 4Division of General Internal Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; 5University of Minnesota Medical School, University of Minnesota, Minneapolis, MN, USA; 6Minneapolis Medical Research Foundation, Minneapolis, MN, USA; 7Department of Social Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; 8Pharmacy Services, Mayo Clinic, Rochester, MN, USA; 9Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; 10Faculty of Health Sciences and NIHR CLAHRC Wessex, University of Southampton, Southampton, UK; 11School of Medicine, University of Virginia, Charlottesville, VA, USA Purpose: The workload of health care and its impact on patient functioning and well-being is known as treatment burden. The purpose of this study was to finalize a conceptual framework of treatment burden that will be used to inform a new patient-reported measure of this construct. Patients and methods: Semi-structured interviews were conducted with 50 chronically ill patients from a large academic medical center (n=32) and an urban safety-net hospital (n=18). We coded themes identifying treatment burden, with the themes harmonized through discussion between multiple coders. Four focus groups, each with five to eight participants with chronic illness, were subsequently held to confirm the thematic structure that emerged from the interviews. Results: Most interviewed patients (98%) were coping with multiple chronic conditions. A preliminary conceptual framework using data from the first 32 interviews was evaluated and was modified using narrative data from 18 additional interviews with a racially and socioeconomically diverse sample of patients. The final framework features three overarching themes with associated subthemes. These themes included: 1) work patients must do to care for their health (eg, taking medications, keeping medical appointments, monitoring health); 2) challenges/stressors that exacerbate perceived burden (eg, financial, interpersonal, provider obstacles); and 3) impacts of burden (eg, role limitations, mental exhaustion). All themes and subthemes were subsequently confirmed in focus groups. Conclusion: The final conceptual framework can be used as a foundation for building a patient self-report measure to systematically study treatment burden for research and analytical purposes, as well as to promote meaningful clinic-based dialogue between patients and providers about the challenges inherent in maintaining complex self-management of health. Keywords: treatment burden, conceptual framework, adherence, questionnaire, self-management, multi-morbidity

Jennifer L Ridgeway,1,2 Jason S Egginton,1,2 Kristina Tiedje,3 Mark Linzer,4,5 Deborah Boehm,4 Sara Poplau,6 Djenane Ramalho de Oliveira,7 Laura Odell,8 Victor M Montori,2,9 David T Eton1,2 1The Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 2Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; 3Department of Anthropology, Université Lumière Lyon 2, Lyon, France; 4Division of General Internal Medicine, Hennepin County Medical Center, 5University of Minnesota Medical School, 6Minneapolis Medical Research Foundation, Minneapolis, MN, USA; 7Department of Social Pharmacy, Universidade Federal de Minas Gerais, Brazil; 8Pharmacy Services, 9Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA Purpose: Patients with multiple chronic conditions (multimorbidity) often require ongoing treatment and complex self-care. This workload and its impact on patient functioning and well-being are, together, known as treatment burden. This study reports on factors that patients with multimorbidity draw on to lessen perceptions of treatment burden. Patients and methods: Interviews (n=50) and focus groups (n=4 groups, five to eight participants per group) were conducted with patients receiving care in a large academic medical center or an urban safety-net hospital. Interview data were analyzed using qualitative framework analysis methods, and themes and subthemes were used to identify factors that mitigate burden. Focus groups were held to confirm these findings and clarify any new issues. This study was part of a larger program to develop a patient-reported measure of treatment burden. Results: Five major themes emerged from the interview data. These included: 1) problem-focused strategies, like routinizing self-care, enlisting support of others, planning for the future, and using technology; 2) emotion-focused coping strategies, like maintaining a positive attitude, focusing on other life priorities, and spirituality/faith; 3) questioning the notion of treatment burden as a function of adapting to self-care and comparing oneself to others; 4) social support (informational, tangible, and emotional assistance); and 5) positive aspects of health care, like coordination of care and beneficial relationships with providers. Additional subthemes arising from focus groups included preserving autonomy/independence and being proactive with providers. Conclusion: Patients attempt to lessen the experience of treatment burden using a variety of personal, social, and health care resources. Assessing these factors in tandem with patient perceptions of treatment burden can provide a more complete picture of how patients fit complex self-care into their daily lives. Keywords: adherence, patient-centered, minimally disruptive medicine, patient preferences

Purpose: To review the literature on diagnostic testing in syncope that remains unexplained after initial clinical assessment.Data Sources: MEDLINE search.Study Selection: Published papers were selected if they addressed diagnostic testing in syncope, near syncope, or dizziness.Data Extraction: Studies were identified as population studies, referral studies, or case series.Data Synthesis: After a thorough history, physical examination, and electrocardiography, the cause of syncope remains undiagnosed in 50% of patients. In such patients, information may be derived from the results of carefully selected diagnostic tests, especially 1) electrophysiologic studies in patients with organic heart disease, 2) Holter monitoring or telemetry in patients known to have or suspected of having heart disease, 3) loop monitoring in patients with frequent events and normal hearts, 4) psychiatric evaluation in patients with frequent events and no injury, and 5) tilt-table testing in patients who have infrequent events or in whom vasovagal syncope is suspected. Hospitalization is indicated for high-risk patients, especially those with known heart disease and elderly patients.Conclusions: A flexible, focused approach is required to diagnose syncope. Features of the initial history and physical examination help guide diagnostic testing. [ABSTRACT FROM AUTHOR]

Purpose: To review the literature on diagnostic testing in syncope and provide recommendations for a comprehensive, cost-effective approach to establishing its cause.Data Sources: Studies were identified through a MEDLINE search (1980 to present) and a manual review of bibliographies of identified articles.Study Selection: Papers were eligible if they addressed diagnostic testing in syncope or near syncope and reported results for at least 10 patients.Data Extraction: The usefulness of tests was assessed by calculating diagnostic yield: the number of patients with diagnostically positive test results divided by the number of patients tested or, in the case of monitoring studies, the sum of true-positive and true-negative test results divided by the number of patients tested.Data Synthesis: Despite the absence of a diagnostic gold standard and the paucity of data from randomized trials, several points emerge. First, history, physical examination, and electrocardiography are the core of the syncope workup (combined diagnostic yield, 50%). Second, neurologic testing is rarely helpful unless additional neurologic signs or symptoms are present (diagnostic yield of electroencephalography, computed tomography, and Doppler ultrasonography, 2% to 6%). Third, patients in whom heart disease is known or suspected or those with exertional syncope are at higher risk for adverse outcomes and should have cardiac testing, including echocardiography, stress testing. Holter monitoring, or intracardiac electrophysiologic studies, alone or in combination (diagnostic yields, 5% to 35%). Fourth, syncope in the elderly often results from polypharmacy and abnormal physiologic responses to daily events. Fifth, long-term loop electrocardiography (diagnostic yield, 25% to 35%) and tilt testing (diagnostic yield < or = 60%) are most useful in patients with recurrent syncope in whom heart disease is not suspected. Sixth, psychiatric evaluation can detect mental disorders associated with syncope in up to 25% of cases. Seventh, hospitalization may be indicated for patients at high risk for cardiac syncope (those with an abnormal electrocardiogram, organic heart disease, chest pain, history of arrhythmia, age > 70 years) or with acute neurologic signs.Conclusions: Many tests for syncope have a low diagnostic yield. A careful history, physical examination, and electrocardiography will provide a diagnosis or determine whether diagnostic testing is necessary in most patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Transient loss of consciousness (TLOC) is a common clinical problem. OBJECTIVE: The aim of this study was to assess the yield and accuracy of the initial evaluation, consisting of standardized history, physical examination, and ECG performed by attending physicians in patients with TLOC. METHODS AND RESULTS: Five hundred and three adult patients (mean age 53 +/- 19; 56% male) presenting with TLOC to the Academic Medical Center Amsterdam between February 2000 and May 2002 were included in this study. After initial evaluation, the physician made a certain, a highly likely (>80% certain), or no initial diagnosis. Initially undiagnosed patients received additional cardiological testing, additional history taking, and autonomic function tests. After 2 years of follow-up, an expert committee determined the final diagnoses. Two-year follow-up was obtained in 99% of the patients. The yield of certain diagnoses after the initial evaluation was 24%, increasing to 63% after including the highly likely diagnoses. The diagnostic accuracy of the initial certain diagnoses was 93% (95% CI 87-97%), decreasing to 88% (95% CI 84-91%) after inclusion of the initial highly likely diagnoses. CONCLUSION: Attending physicians can make a diagnosis based on initial evaluation in 63% of patients with TLOC, with an overall diagnostic accuracy of 88%. The use of additional testing, beyond history, physical examination, and ECG can be avoided in many patients with TLOC. [ABSTRACT FROM AUTHOR]

BACKGROUND: A report by the Institute of Medicine suggests that changing the culture of health care organizations may improve patient safety. Research in this area, however, is modest and inconclusive. Because culture powerfully affects providers, and providers are a key determinant of care quality, the MEMO study (Minimizing Error, Maximizing Outcome) introduces a new model explaining how physician work attitudes may mediate the relationship between culture and patient safety. RESEARCH QUESTIONS: (1) Which cultural conditions affect physician stress, dissatisfaction, and burnout? and (2) Do stressed, dissatisfied, and burned out physicians deliver poorer quality care? METHODS: A conceptual model incorporating the research questions was analyzed via structural equation modeling using a sample of 426 primary care physicians participating in MEMO. FINDINGS: Culture, overall, played a lesser role than hypothesized. However, a cultural emphasis on quality played a key role in both quality outcomes. Further, we found that stressed, burned out, and dissatisfied physicians do report a greater likelihood of making errors and more frequent instance of suboptimal patient care. PRACTICE IMPLICATIONS: Creating and sustaining a cultural emphasis on quality is not an easy task, but is worthwhile for patients, physicians, and health care organizations. Further, having clinicians who are satisfied and not burned out or stressed contributes substantially to the delivery of quality care. [ABSTRACT FROM AUTHOR]

INTRODUCTION: There are limited and conflicting data on the lifetime cumulative incidence of syncope in the general population. The aim of our study was to determine the lifetime cumulative incidence and triggers of syncope in the general population. METHODS: Questions about syncope were added to a cross-sectional survey on cardiovascular risk factors carried out between 2001 and 2003 in 549 native Dutch respondents, aged 35-60 years. RESULTS: The lifetime cumulative incidence of syncope in our study population was 35% (95% confidence interval 31-39%). Syncope occurred more often in women than in men (41% vs 28%; P = 0.003). A peak in the incidence of syncope occurred around the age of 15 years in both men and women. The median number of episodes in persons with syncope was 2 (Inter Quartile Range 1-5). The top five most frequently mentioned triggers of syncope included warm environment, pain, insufficient food intake, seeing blood/venipuncture, and emotion. CONCLUSION: In conclusion, our study shows that the lifetime cumulative incidence of syncope in the general population is high. Females experience syncope more often than males. The majority of the syncope triggers were related to conditions that affect orthostatic blood pressure regulation and vasomotor responses. [ABSTRACT FROM AUTHOR]

Understanding the effect that physician stress and burnout have on patient outcomes is important to improving the quality of care. The physician-patient cycle model documents the virtuous or vicious cycles which can ensue when clinicians deal effectively or ineffectively with stress and burnout. The model starts with excessive stress beginning the physician burnout process. Ineffectual physician responses to burnout, including depersonalizing behaviors, negatively affect the quality of the medical encounter. Poor quality encounters engender low patient satisfaction, poor compliance with medical treatments, and more patient assertiveness. For physicians, these patient attitudes and behaviors may be perceived as patient demands and experienced as additional stressors, perpetuating a vicious cycle. The model contributes to the knowledge base on stress and health by synthesizing various studies that have examined physician stress and burnout as they impact patient outcomes. A major implication is that the well-being of physicians is a key ingredient to the provision of quality medical care. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective: To assess the association between HMO practice, time pressure, and physician job satisfaction.Design: National random stratified sample of 5,704 primary care and specialty physicians in the United States. Surveys contained 150 items reflecting 10 facets (components) of satisfaction in addition to global satisfaction with current job, one's career and one's specialty. Linear regression-modeled satisfaction (on 1-5 scale) as a function of specialty, practice setting (solo, small group, large group, academic, or HMO), gender, ethnicity, full-time versus part-time status, and time pressure during office visits. "HMO physicians" (9% of total) were those in group or staff model HMOs with > 50% of patients capitated or in managed care.Results: Of the 2,326 respondents, 735 (32%) were female, 607 (26%) were minority (adjusted response rate 52%). HMO physicians reported significantly higher satisfaction with autonomy and administrative issues when compared with other practice types (moderate to large effect sizes). However, physicians in many other practice settings averaged higher satisfaction than HMO physicians with resources and relationships with staff and community (small to moderate effect sizes). Small and large group practice and academic physicians had higher global job satisfaction scores than HMO physicians (P <.05), and private practice physicians had quarter to half the odds of HMO physicians of intending to leave their current practice within 2 years (P <.05). Time pressure detracted from satisfaction in 7 of 10 satisfaction facets (P <.05) and from job, career, and specialty satisfaction (P <.01). Time allotted for new patients in HMOs (31 min) was less than that allotted in solo (39 min) and academic practices (44 min), while 83% of family physicians in HMOs felt they needed more time than allotted for new patients versus 54% of family physicians in small group practices (P <.05 after Bonferroni's correction).Conclusions: HMO physicians are generally less satisfied with their jobs and more likely to intend to leave their practices than physicians in many other practice settings. Our data suggest that HMO physicians' satisfaction with staff, community, resources, and the duration of new patient visits should be assessed and optimized. Whether providing more time for patient encounters would improve job satisfaction in HMOs or other practice settings remains to be determined. [ABSTRACT FROM AUTHOR]

Objective: To describe gender differences in job satisfaction, work life issues, and burnout of U.S. physicians.Design/participants: The Physician Work life Study, a nationally representative random stratified sample of 5,704 physicians in primary and specialty nonsurgical care (N = 2,326 respondents; 32% female, adjusted response rate = 52%). Survey contained 150 items assessing career satisfaction and multiple aspects of work life.Measurements and Main Results: Odds of being satisfied with facets of work life and odds of reporting burnout were modeled with survey-weighted logistic regression controlling for demographic variables and practice characteristics. Multiple linear regression was performed to model dependent variables of global, career, and specialty satisfaction with independent variables of income, time pressure, and items measuring control over medical and workplace issues. Compared with male physicians, female physicians were more likely to report satisfaction with their specialty and with patient and colleague relationships (P <.05), but less likely to be satisfied with autonomy, relationships with community, pay, and resources (P <.05). Female physicians reported more female patients and more patients with complex psychosocial problems, but the same numbers of complex medical patients, compared with their male colleagues. Time pressure in ambulatory settings was greater for women, who on average reported needing 36% more time than allotted to provide quality care for new patients or consultations, compared with 21% more time needed by men (P <.01). Female physicians reported significantly less work control than male physicians regarding day-to-day aspects of practice including volume of patient load, selecting physicians for referrals, and details of office scheduling (P <.01). When controlling for multiple factors, mean income for women was approximately $22,000 less than that of men. Women had 1.6 times the odds of reporting burnout compared with men (P <.05), with the odds of burnout by women increasing by 12% to 15% for each additional 5 hours worked per week over 40 hours (P <.05). Lack of workplace control predicted burnout in women but not in men. For those women with young children, odds of burnout were 40% less when support of colleagues, spouse, or significant other for balancing work and home issues was present.Conclusions: Gender differences exist in both the experience of and satisfaction with medical practice. Addressing these gender differences will optimize the participation of female physicians within the medical workforce. [ABSTRACT FROM AUTHOR]

The purpose of this article is to review the literature and present new data concerning the relationship between psychiatric disorders and unexplained syncope. Several case series are presented of patients with syncope in whom psychiatric structured interviews were undertaken, tilt-table (physiologic) testing was performed, and health-related quality of life was measured. Patients seen in a syncope specialty clinic underwent structured psychiatric interviews in addition to in-depth medical evaluations. Tilt-table testing was performed on a separate series of patients to determine susceptibility to syncope during the orthostatic challenge of head-up tilt; in some cases, tilt studies included simultaneous electroencephalographic (EEG) monitoring and cerebral blood flow measurements. Formal functional status assessment was carried out using the Sickness Impact Profile, the Symptom Check List 90, and the Medical Outcomes Study Short-Form 36. Psychiatric disorders (in particular, panic disorders and major depression) were a common cause of syncope (24-31% of syncope patients). Tilt table studies showed several physiologic profiles in syncope: (a) a typical vasovagal (hypotension-bradycardia) response, (b) a "psychosomatic" response (fainting with normal vital signs), and (c) a gradual decline in blood pressure (dysautonomic response). EEG and cerebral blood flow measurements in three patients with the psychosomatic response to tilt were normal during fainting. Functional status measurements showed serious impairment in two series of syncope patients. Conclusions were as follows: (a) Psychiatric disorders are common in syncope. (b) Tilt-table methodology may elucidate underlying mechanisms of syncope in these subjects. (c) Syncope can seriously disrupt a patient's life and result in important psychosocial sequelae. (d) There is an intimate relationship between unexplained syncope and psychiatric illness, mandating a combined medical and psychiatric approach to such patients. [ABSTRACT FROM AUTHOR]

Objective: To determine the factors that attract students toward and push students away from a career in internal medicine.Design: National survey of senior U.S. medical students using a stratified random cluster sampling of medical schools.Participants: The survey included 1650 U.S. senior students from 16 medical schools, of whom 1244 (76%) responded.Measurements and Main Results: A survey instrument was developed and pilot tested at 17 medical schools. Twenty-four percent of the respondents to the final survey chose a career in general internal medicine (9%) or subspecialty internal medicine (15%). A career in internal medicine had been "seriously considered" by 608 respondents (50%) who finally chose a career other than internal medicine (the "switchers"). Compared with other specialties, internal medicine was perceived as being more stressful to residents, more demanding of time and workload as a career and a residency, and as an easier residency to enter. Internal medicine was also seen as providing less satisfaction for residents, having lower income potential, and allowing less leisure time. For the 608 switchers, the most important influences leading to their decision to switch were the type of patient seen in internal medicine (for example, chronically ill, alcohol and drug abusing patients) as well as dissatisfaction and stress among internal medicine residents. Factor analysis showed that three factors, "intellectual challenge of internal medicine," "primary care interests," and "the medicine clerkship" attracted students toward internal medicine, whereas three others, "taking care of chronically ill patients," "level of satisfaction among internists and medical residents," and "workload and stress" pushed students away from internal medicine. Factors pushing students away from internal medicine were significantly more negative with regard to a career in general as opposed to subspecialty internal medicine (P less than 0.001).Conclusion: Medical students have serious reservations about internal medicine as a career choice. Perceptions about the medical residency, the patients they expect to see, and the dissatisfaction among residents and internists are foremost in their thinking. Changes to improve the attractiveness of internal medicine should address these adverse perceptions while building on the positive influences identified by the respondents. [ABSTRACT FROM AUTHOR]

A unique scanning Michelson interferometric system has been implemented with decided advantages over previous schemes for accurate measurement of the complex components of ultrasonic fields over wide apertures. Amplitude and phase information from transducers and scattering objects was acquired over 100 mm×100 mm planes using both narrowband (gated cw) and wideband (pulse) insonification. Ultrasonic wavefronts at other planes and reconstructions of the test objects were computed by means of a fast Fourier transform technique based on the angular spectrum of plane-waves approach. A critical review of wavefront reconstruction methods was also carried out. [ABSTRACT FROM AUTHOR]

Objective: To determine the proportion of primary care patients who are experienced by their physicians as "difficult," and to assess the association of difficulty with physical and mental disorders, functional impairment, health care utilization, and satisfaction with medical care.Design: Survey.Setting: Four primary care clinics.Patients: Six-hundred twenty-seven adult patients.Measurements: Physician perception of difficulty (Difficult Doctor-Patient Relationship Questionnaire), mental disorders and symptoms (Primary Care Evaluation of Mental Disorders, [PRIME-MDI]), functional status (Medical Outcomes Study Short-Form Health Survey [SF-20]), utilization of and satisfaction with medical care by patient self-report.Results: Physicians rated 96 (15%) of their 627 patients as difficult (site range 11-20%). Difficult patients were much more likely than not-difficult patients to have a mental disorder (67% vs 35% [corrected], p < .0001). Six psychiatric disorders had particularly strong associations with difficulty: multisomatoform disorder (odds ratio [OR] = 12.3. 95% confidence interval [CI] = 5.9-26.8), panic disorder (OR = 6.9, 95% CI = 2.6-18.1), dysthymia (OR = 4.2, 95% CI = 2.0-8.7), generalized anxiety (OR = 3.4, 95% CI = 1.7-7.1), major depressive disorder (OR = 3.0, 95% CI = 1.8-5.3), and probable alcohol abuse or dependence (OR = 2.6, 95% CI = 1.01-6.7). Compared with not-difficult patients, difficult patients had more functional impairment, higher health care utilization, and lower satisfaction with care, whereas demographic characteristics and physical illnesses were not associated with difficulty. The presence of mental disorders accounted for a substantial proportion of the excess functional impairment and dissatisfaction in difficult patients.Conclusions: Difficult patients are prevalent in primary care settings and have more psychiatric disorders, functional impairment, health care utilization, and dissatisfaction with care. Future studies are needed to determine whether improved diagnosis and management of mental disorders in difficult patients could diminish their excess disability, health care costs, and dissatisfaction with medical care, as well as the physicians experience of difficulty. [ABSTRACT FROM AUTHOR]

Objective: To determine whether students who take ambulatory rotations in internal medicine are more likely to choose internal medicine careers.Design: National survey.Setting and Participants: The intended sample was 1,650 senior U.S. medical students from 16 medical schools, of whom 1,244 (76%) responded. Representative schools nationwide were selected using a stratified, random-sampling method.Measurements: The questionnaire asked about characteristics of the ambulatory rotation, perceptions of internal medicine, and factors influencing students toward or away from an internal medicine career.Results: Ambulatory rotations were taken by 543 students (43%). Of these rotations, 73% were required, 74% were during the fourth year, 77% were in general internal medicine, 73% provided continuity of care, and 19% were during the medicine clerkship. Overall, 24% of the students chose careers in general (9%) or subspecialty internal medicine (15%). Thirty percent of the students who did ambulatory rotations planned internal medicine careers, compared with 19% of the students who had no rotation [odds ratio (OR) = 1.8, 95% confidence interval (CI) 1.3 to 2.4, p = 0.0001]. This association was of similar magnitudes for students completing required rotations (OR = 1.6, 95% CI 1.2 to 2.2, p = 0.002) and for students completing rotations before or in proximity to when they chose careers (OR = 1.7, 95% CI 1.1 to 2.4, p = 0.01). Ninety percent of the 543 students who had ambulatory rotations were satisfied with the experience. Thirty-eight percent of the highly satisfied students chose internal medicine careers, compared with 21% of the students who had low or moderate satisfaction (p = 0.0001).Conclusions: An ambulatory rotation is strongly associated with positive perceptions of, attraction to, and choice of a career in internal medicine. Research is needed to determine specific components of an effective rotation. Further development of ambulatory rotations could help attract more students to internal medicine. [ABSTRACT FROM AUTHOR]

As the country strives to produce larger numbers of generalist physicians, considerable controversy has arisen over whether or not generalist applicants can be identified, recruited, and influenced to keep a generalist-oriented commitment throughout medical training. The authors present new and existing data to show that: 1) preadmission (BA/MD or post-baccalaureate) programs can help to identify generalist-oriented students; 2) characteristics determined at admission to medical school are predictive of future generalist career choice; 3) current inpatient-oriented training programs strongly push students away from a primary care career; 4) women are more likely than men to choose generalist careers, primarily because of those careers' interpersonal orientation; and 5) residency training programs are able to select applicants likely to become generalists. Therefore, to produce more generalists, attempts should be made to encourage generalist-oriented students to enter medical schools and to revise curricula to focus on outpatient settings in which students can establish effective and satisfying relationships with patients. These strategies are most likely to be successful if enacted within the context of governmental and medical school-based changes that allow for more reimbursement and respect for the generalist disciplines. [ABSTRACT FROM AUTHOR]

Background: A disease-specific measure of functional health in syncope would provide an important outcome measure for use either in clinical trials or in the clinical management of patients with recurrent syncope.Methods and Measurements: In a previous study the authors used formal functional status measures to determine physical and psychosocial impairment in recurrent syncope. This study provides a preliminary assessment of a disease-specific measure of function. The measure was pilot tested on 84 subjects, and validated in a separate cohort of 49 patients. The measure consists of 1) an 11-question matrix of yes/no questions, assessing the ways that syncope interferes with a patient's life (the result is expressed as a proportion of the total number of ways that syncope might interfere and is called the Impairment Score), and 2) three Likert-scale questions that assess the patient's fear and worry about syncope. Correlations were obtained between scores on the disease-specific measure and other measures of functional health.Results: Among the 49 patients in the test cohort, final scores on the disease-specific measure correlated with both physical and psychosocial dimension scores on a measure of functional status, the Sickness Impact Profile (r = 0.35-0.36, p = 0.01), and with five of ten subscale scores on a measure of psychological distress, the Symptom Checklist 90-R (r = 0.30-0.43, p = 0.004-0.02).Conclusions: This new disease-specific quality-of-life measure in syncope measures both physical and psychosocial components of impairment and could be a valuable adjunct in measuring outcomes in syncope patients. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of acute cardiac ischemia in emergency department (ED) syncope patients without chest pain and to determine which of these patients are at high risk for acute cardiac ischemia.Design: Data were collected prospectively during a study of ED triage of patients who had had possible acute cardiac ischemia. Supplemental retrospective review of records was performed to differentiate syncope from dizziness.Setting: Six hospital EDs in New England (two primary teaching hospitals in urban locations, two medical-school-affiliated teaching hospitals, and two nonteaching hospitals in rural settings).Patients: 5,762 patients had presented to the ED with chief complaints consistent with acute cardiac ischemia, including chest pain, shortness of breath, dizziness, and syncope. The study sample consisted of 251 patients who had had syncope and no chest pain.Results: The prevalence of acute cardiac ischemia among the syncope patients was 7% (18 of the 251 patients). Univariate analysis revealed the following to have significant association with acute cardiac ischemia: ischemic abnormalities on the electrocardiogram (ECG) obtained in the ED (p less than 0.001), arm or shoulder pain on presentation (p less than 0.05), rales (p less than 0.1), and prior history of exercise-induced angina (p less than 0.05) or myocardial infarction (p less than 0.1). All 18 patients with acute cardiac ischemia had ischemic abnormalities (pathologic Q waves, ST-segment elevation or depression, or T-wave abnormalities) on their presenting ECGs.Conclusion: For syncope patients who have no chest pain or ischemic abnormality on the presenting ECG in the ED, acute ischemia appears to be unlikely. Admission to the cardiac care unit for these patients for possible myocardial ischemia is probably unnecessary. However, patients who have syncope and ischemic abnormalities on the ECG are at risk for acute cardiac ischemia, even in the absence of chest pain. Hospital admission to rule out myocardial infarction for these patients is prudent. [ABSTRACT FROM AUTHOR]

Purpose: To develop and validate a predictive model that would allow clinicians to determine whether an electrophysiologic (EP) study is likely to result in useful diagnostic information for a patient who has unexplained syncope.Patients: One hundred seventy-nine consecutive patients with unexplained syncope who underwent EP studies at two university medical centers comprised the training sample. A test sample to validate the model was made up of 138 patients from the clinical literature who had undergone EP studies for syncope.Design: Retrospective analysis of patients undergoing EP studies for syncope. The data collector was blinded to the study hypothesis; the electrophysiologist assessing outcomes was blinded to clinical and historical data. Clinical predictor variables available from the history, the physical examination, electrocardiography (ECG), and Holter monitoring were analyzed via two multivariable predictive modeling strategies (ordinal logistic regression and recursive partitioning) for their abilities to predict the results of EP studies, namely tachyarrhythmic and bradyarrhythmic outcomes. These categories were further divided into full arrhythmia and borderline arrhythmia groups.Results: Important outcomes were 1) sustained monomorphic ventricular tachycardia (VT) and 2) bradyarrhythmias, including sinus node and atrioventricular (AV) conducting disease. The results of the logistic regression (in this study, the superior strategy) showed that the presence of organic heart disease [odds ratio (OR) = 3.0, p less than 0.001] and frequent premature ventricular contractions on ECG (OR = 6.7, p less than 0.004) were associated with VT, while the following abnormal ECG findings were associated with bradyarrhythmias: first-degree heart block (OR = 7.9, p less than 0.001), bundle-branch block (OR = 3.0, p less than 0.02), and sinus bradycardia (OR = 3.5, p less than 0.03). Eighty-seven percent of the 31 patients with important outcomes at EP study had at least one of these clinical risk factors, while 95% of the patients with none of these risk factors had normal or nondiagnostic EP studies. In the validation sample, the presence of one or more risk factors would have correctly identified 88% of the test VT patients and 65% of the test bradyarrhythmia patients as needing EP study.Conclusion: These five identified predictive factors, available from the history, the physical examination, and the initial ECG, could be useful to clinicians in selecting those patients with unexplained syncope who will have a serious arrhythmia identified by EP studies. [ABSTRACT FROM AUTHOR]