Search

Objective: Despite the proliferation of electronic information retrieval (IR) systems for physicians, their effectiveness has not been well assessed. The purpose of this review is to provide a conceptual framework and to apply the results of previous studies to this framework.Data Sources: All sources of medical informatics and information science literature, including MEDLINE, along with bibliographies of textbooks in these areas, were searched from 1966 to January 1998.Study Selection: All articles presenting either classifications of evaluation studies or their results, with an emphasis on those studying use by physicians.Data Extraction: A framework for evaluation was developed, consisting of frequency of use, purpose of use, user satisfaction, searching utility, search failure, and outcomes. All studies were then assessed based on the framework.Data Synthesis: Due to the heterogeneity and simplistic study designs, no meta-analysis of studies could be done. General conclusions were drawn from data where appropriate. A total of 47 articles were found to include an evaluation component and were used to develop the framework. Of these, 21 articles met the inclusion criteria for 1 or more of the categories in the framework. Most use of IR systems by physicians still occurs with bibliographic rather than full-text databases. Overall use of IR systems occurs just 0.3 to 9 times per physician per month, whereas physicians have 2 unanswered questions for every 3 patients.Conclusions: Studies comparing IR systems with different searching features have not shown that advanced searching methods are significantly more effective than simple text word methods. Most searches retrieve only one fourth to one half of the relevant articles on a given topic and, once retrieved, little is known about how these articles are interpreted or applied. These studies imply that further research and development are needed to improve system utility and performance. [ABSTRACT FROM AUTHOR]

Objective: To determine whether personal characteristics influence residents' psychological states during training and to evaluate the relative importance of personal characteristics and psychological states in predicting clinical performance.Design: Cohort study utilizing prospective, serial surveys of emotions (anxiety, depression, competence) and attitudes (satisfaction with the decision to become a physician) among two classes of internal medicine residents during all years of their training. Subjects completed a socio-demographic survey at the conclusion of training, and faculty-assigned clinical ranks and examination scores were used to rate their clinical performances.Main Results: Personal characteristics had a stronger relationship to psychological states during the first training year than in subsequent years. The highest association was found for depression, for which 25% of the variation was accounted for by personal characteristics. The combination of personal characteristics and psychological states explained 48% of the variation in clinical ranks and 38% of the variation in American Board of Internal Medicine certifying examination scores.Conclusion: There are recognizable relationships among the personal characteristics of residents, their psychologic states during training, and their clinical performances. These results should be helpful to program directors and faculty in identifying potentially weak residents and avoiding pitfalls when working with troubled residents. [ABSTRACT FROM AUTHOR]

Objective: To assess how patients use graphic data to decide on preferences between alternative treatments.Design: Cross-sectional survey of patients, physicians, and medical students. The physicians and medical students served as a control group with which to compare the patients' responses.Setting: A university-based Department of Veterans Affairs Medical Center.Participants: 152 patients seen in a general medicine clinic, 57 medical students, and 11 physicians.Measurements and Results: Subjects were given a survival graph showing the patient outcomes for two different unidentified treatments for an unidentified serious disease. They were asked to indicate which treatment they preferred and which portion(s) of the curves most influenced their preference. A large majority of both patients and health professionals preferred the treatment that had worse short-term and better long-term survival. Eleven percent of patients and 51% of health professionals identified mid-curve data (points other than the curve end-points) as most influencing their preferences.Conclusions: A graphic survival curve appears to provide enough information to assess patient preferences between two alternative treatments. Patients appeared to differ from physicians and medical students in their interpretation of the curves. [ABSTRACT FROM AUTHOR]

The authors conducted a randomized trial of two methods for teaching medical students how to estimate the probability of coronary artery disease in patients with chest pain. Eighty-two students were given a pre-test consisting of written protocols summarizing the histories of 25 patients who had undergone coronary arteriography. The students estimated the likelihood of coronary artery disease for each case and were then randomized to receive one of two short written clinical lessons: a cardiology textbook chapter on interpreting chest pain, or a lesson based on a prediction rule for estimating probability of coronary artery disease. All students were given a post-test similar to the pre-test. Students who were given the textbook lesson showed no change in the accuracy of their probability estimates. Students who were taught the prediction rule significantly improved their probability estimates, as measured by a statistical index of calibration. The authors conclude that traditional teaching methods do not provide students with guidance in estimating disease probability, and that better teaching methods are needed. In this study, a clinical prediction rule fulfilled the need for instruction in probability estimation. [ABSTRACT FROM AUTHOR]

The authors evaluated the perceptions and adjustments of surviving spouses following patient deaths. Of 128 married patients dying in a university hospital in 1983, the surviving spouses of 105 (82%) were personally interviewed a year after the death. The physicians' perspectives were recorded through chart review. Half of all spouses had had no subsequent contact with the physicians who had cared for the decreased, and 55% of spouses still had unanswered questions regarding the death a year later. Survivors of unexpected deaths were found to be at high risk for poor subsequent adjustment. Spouses with poorer adjustments consulted their own physicians more frequently, and used more alcohol and tranquilizers. The results identify areas where improvement is needed in communication with surviving spouses after patients' deaths. [ABSTRACT FROM AUTHOR]

As transplantation success rates have improved, the demand for donor organs has steadily increased. A shortage of donor organs has led to legislation requiring hospital personnel to provide families routinely with the opportunity to authorize organ donation. Primary physicians have an important role in identifying potential donors while continuing to assure that the survivors' needs are met. The major implications of organ donation for the primary physician are reviewed. Patients who die will more frequently be eligible as cornea, skin, or bone donors, but the criteria for both tissue and internal organ donation are reviewed. Ethical issues unique to organ donation and responses of survivors to donation requests are described. If appropriately offered, the opportunity to authorize an anatomic gift can be a source of comfort to survivors while the donation provides the benefits of transplantation to persons on organ waiting lists. [ABSTRACT FROM AUTHOR]

Objective: To assess the level of involvement patients want in decision making related to the acceptance or rejection of an invasive medical intervention and whether their preference for decision making is related to their preference for qualitative (verbal) or quantitative (numeric) information about the risks of the procedure.Setting: A university-based Department of Veterans Affairs Medical Center.Design: Cross-sectional study using structured interviews of consecutive patients seen for continuity care visits in a general medicine clinic.Patients: Four hundred and sixty-seven consecutive patients with a mean age of 65.2 years (SD 10.70 years, range 31-88 years) and with a mean of 12.6 years (SD 2.96 years, range 0-24 years) of formal education.Measurements and Main Results: In the context of an invasive diagnostic or therapeutic intervention, patients were asked whether they preferred patient-based, physician-based, or shared patient-physician decision making. Patients were asked to give the ratio of patient-to-physician decision making they preferred, and whether they preferred discussions using words, numbers, or both. Of 467 subjects, 318 (68%) preferred shared decision making; 100 (21.4%) preferred physician-based decision making; and 49 (10.5%) preferred patient-based decision making. In terms of risk disclosure, 436 (93.4%) preferred that their physician disclose risk information to them. Of these 436 patients, 42.7% preferred disclosure of information about the probability of adverse outcomes using qualitative (verbal) expressions of probability; 35.7% preferred disclosure in terms of quantitative (numeric) expressions of probability; and 9.8% preferred disclosure in both qualitative and quantitative terms. Younger patients (odds ratio [OR] 0.96; confidence interval [CI] 0.93, 0.99), patients who had at least one stroke (OR 3.03; CI 1.03, 8.90), and patients who preferred to discuss risk information with their physicians in terms of numbers (OR 2.39; CI 1.40, 4.06) tended to prefer patient-based or shared decision making.Conclusions: Male veterans consistently preferred shared patient-physician decision making in the context of invasive medical interventions. [ABSTRACT FROM AUTHOR]

Objective: To determine whether an intervention designed to improve patient-physician communication increases the frequency with which physicians elicit patients' concerns, changes other communication behaviors, and improves health care outcomes.Design: Pretest-posttest design with random assignment of physicians to intervention or control groups.Setting: General medicine clinics of a university-affiliated Veterans Affairs Hospital.Patients/participants: Forty-two physicians and 348 continuity care patients taking prescription medications for chronic medical conditions.Interventions: Intervention group physicians received 4.5 hours of training on eliciting and responding to patients' concerns and requests, and their patients filled out the Patient Requests for Services Questionnaire prior to a subsequent clinic visit. Control group physicians received 4.5 hours of training in medical decision-making.Measurements and Main Results: The frequency with which physicians elicited all of a patient's concerns increased in the intervention group as compared with the control group (p = .032). Patients perceptions of the amount of information received from the physician did increase significantly (p < .05), but the actual magnitude of change was small. A measure of patient satisfaction with the physicians was high at baseline and also showed no significant change after the intervention. Likewise, the intervention was not associated with changes in patient compliance with medications or appointments, nor were there any effects on outpatient utilization.Conclusions: A low-intensity intervention changed physician behavior but had no effect on patient outcomes such as satisfaction, compliance, or utilization. Interventions may need to focus on physicians and patients to have the greatest effect. [ABSTRACT FROM AUTHOR]

Objective: To assess outpatients' attitudes toward and understanding of a standard living will.Design: Survey using a self-administered questionnaire that patients completed after they had read a sample living will.Setting: General medicine clinic of a Department of Veterans Affairs medical center.Patients: Two hundred fourteen patients (85% of those approached) attending a continuity care clinic appointment. Eighty-seven percent were men; mean age was 60 years.Measurements and Main Results: Patients' attitudes toward living wills, understanding of the terminology contained in living wills, desire to discuss living wills with their doctors, and desire to prepare a living will.Results: Seventy-two percent of the patients had prior knowledge of living wills, though only 53% had discussed the topic with family members and only 14% with physicians. Half felt that the living will terminology should be simplified, and 55% were unable to identify the correct definition for at least one commonly used term. Desire to prepare a living will was positively associated with better understanding of the sample document and previous knowledge of and exposure to living wills, and was negatively associated with concern about its use and revocability (all p < 0.001). Patients who reported poor understanding of the living will were more likely to want to discuss the topic with a physician (p < 0.01).Conclusions: In this ambulatory patient population attitudes toward living wills were influenced by knowledge and understanding of these documents. Primary care physicians and institutions should develop patient education strategies that enhance understanding of advance directives. [ABSTRACT FROM AUTHOR]

We conducted a prospective controlled trial to determine whether an educational intervention could improve resident physician self-efficacy and counseling behaviors for physical activity and increase their patients' reported activity levels. Forty-eight internal medicine residents who practiced at a Department of Veterans Affairs hospital received either two workshops on physical activity counseling or no intervention. All residents completed questionnaires before and 3 months after the workshops. The 21 intervention physicians reported increased self-efficacy for counseling and increased frequency of counseling compared with the 27 control physicians. Approximately 10 patients of each resident were included in the study and surveyed before and 6 months after the intervention. Of 560 patients, 465 (83%) returned both questionnaires. Following the intervention, there were no significant differences between patients of intervention and control physicians on any outcome measures. We conclude that educational interventions can improve physicians' reported self-efficacy of physical activity counseling but may not increase patient physical activity levels. Alternative approaches that emphasize overcoming the substantial barriers to exercise in chronically ill outpatients clearly will be important for facilitating changes in physical activity. [ABSTRACT FROM AUTHOR]

The article focuses on a research that analyzes the significance of decision support for primary care clinicians in improving the outcomes for people with depression. For the study, forty one primary core clinicians were randomised and all their patients with moderate to severe depression were included. The study showed that depression decision support for primary care clinicians did not improve symptoms in people with moderate to severe depression.

Objectives: Despite the growing use of online databases by clinicians, there has been very little research documenting how effectively they are used. This study assessed the ability of medical and nurse-practitioner students to answer clinical questions using an information retrieval system. It also attempted to identify the demographic, experience, cognitive, personality, search mechanics, and user-satisfaction factors associated with successful use of a retrieval system., Methods: Twenty-nine students completed questionnaires of clinical and computer experience as well as tests of cognitive abilities and personality type. They were then administered three clinical questions to answer in a medical library setting using the MEDLINE database and electronic and print full-text resources., Results: Medical students were able to answer more questions correctly than nurse-practitioner students before and after searching, but both had comparable improvements in the number of correct questions before and after searching. Successful ability to answer questions was also associated with having experience in literature searching and higher standardized test-score percentiles., Conclusions: Medical and nurse-practitioner students obtained comparable benefits in the ability to answer clinical questions from use of the information retrieval system. Future research must examine strategies that improve successful search and retrieval of clinical questions posed by clinicians in practice.

To assess how patients' preferences for non-numerical risk information are related to their tendency to choose early surgical treatment for asymptomatic gland-confined prostate cancer (a choice with high risk and high therapeutic uncertainty), the authors conducted a cross-sectional study of 228 patients receiving continuing care in a general medicine clinic. After being provided with three data disclosures related to the treatment decision, subjects were given a choice between surgery-now and watchful waiting. Data about surgical complications were presented in numerical format. The subjects were also asked whether they preferred communication with their physician about the chance (probability) of adverse outcomes-related to management strategies-in terms of words (such as possible or probable) or numbers (such as percentages). Of the 226 patients who chose either surgery-now or watchful waiting, 71.2% preferred risk information in terms of words only or numbers only: 44% words only, and 56% numbers only. Younger patients (OR = 1.06 per year; CI = 1.02-1.10, p = 0.0008) and those wanting risk communication in terms of words only (OR = 2.41; CI = 1.24-4.70, p = 0.01) tended to prefer surgery-now over watchful waiting as the management strategy for asymptomatic gland-confined prostate carcinoma. The authors conclude that there is a significant association between patients' preferences for risk communication with their physicians in terms of words only and a tendency to prefer early surgical intervention for prostate cancer when surgical risk data are provided numerically.

We conducted a prospective controlled trial to determine whether an educational intervention could improve resident physician self-efficacy and counseling behaviors for physical activity and increase their patients' reported activity levels. Forty-eight internal medicine residents who practiced at a Department of Veterans Affairs hospital received either two workshops on physical activity counseling or no intervention. All residents completed questionnaires before and 3 months after the workshops. The 21 intervention physicians reported increased self-efficacy for counseling and increased frequency of counseling compared with the 27 control physicians. Approximately 10 patients of each resident were included in the study and surveyed before and 6 months after the intervention. Of 560 patients, 465 (83%) returned both questionnaires. Following the intervention, there were no significant differences between patients of intervention and control physicians on any outcome measures. We conclude that educational interventions can improve physicians' reported self-efficacy of physical activity counseling but may not increase patient physical activity levels. Alternative approaches that emphasize overcoming the substantial barriers to exercise in chronically ill outpatients clearly will be important for facilitating changes in physical activity.

Objective: To assess the level of involvement patients want in decision making related to the acceptance or rejection of an invasive medical intervention and whether their preference for decision making is related to their preference for qualitative (verbal) or quantitative (numeric) information about the risks of the procedure., Setting: A university-based Department of Veterans Affairs Medical Center., Design: Cross-sectional study using structured interviews of consecutive patients seen for continuity care visits in a general medicine clinic., Patients: Four hundred and sixty-seven consecutive patients with a mean age of 65.2 years (SD 10.70 years, range 31-88 years) and with a mean of 12.6 years (SD 2.96 years, range 0-24 years) of formal education., Measurements and Main Results: In the context of an invasive diagnostic or therapeutic intervention, patients were asked whether they preferred patient-based, physician-based, or shared patient-physician decision making. Patients were asked to give the ratio of patient-to-physician decision making they preferred, and whether they preferred discussions using words, numbers, or both. Of 467 subjects, 318 (68%) preferred shared decision making; 100 (21.4%) preferred physician-based decision making; and 49 (10.5%) preferred patient-based decision making. In terms of risk disclosure, 436 (93.4%) preferred that their physician disclose risk information to them. Of these 436 patients, 42.7% preferred disclosure of information about the probability of adverse outcomes using qualitative (verbal) expressions of probability; 35.7% preferred disclosure in terms of quantitative (numeric) expressions of probability; and 9.8% preferred disclosure in both qualitative and quantitative terms. Younger patients (odds ratio [OR] 0.96; confidence interval [CI] 0.93, 0.99), patients who had at least one stroke (OR 3.03; CI 1.03, 8.90), and patients who preferred to discuss risk information with their physicians in terms of numbers (OR 2.39; CI 1.40, 4.06) tended to prefer patient-based or shared decision making., Conclusions: Male veterans consistently preferred shared patient-physician decision making in the context of invasive medical interventions.

Background: Although the case presentation is a frequent activity, little is known about the attributes that faculty members use when assessing case presentation ability., Purpose: Define the dimensions used by faculty when assessing students' case presentation abilities., Methods: Eleven internal medicine faculty members independently assessed the same 17 videotaped student case presentations. Raters used an evaluation form assembled with 4 descriptors of content and 6 attributes of communication style. For each evaluator, correlation analyses were used to examine associations among the individual descriptors and a student's overall evaluation., Results: Despite efforts toward uniform scoring, faculty evaluators varied in their application of rating criteria. The majority of raters had significant (p < .01) correlation between 4 of the 10 dimensions and the overall score. These 4 were history of present illness and three communication skills: economy, fluency, and precision of language., Conclusions: Faculty members' assessment of case presentations is based on both the facts presented and communication style. These identified performance dimensions can facilitate teaching students to present cases and allow more informative feedback on their abilities.

Objective: To determine the influence of alternative explanations by physicians of the purpose of a medical intervention (intubation and ventilatory support, IVS) on three types of patient preferences: desire for IVS, the length of time patients would find IVS acceptable, and the minimum probability of a good medical outcome patients would require before assenting to continued support with IVS., Methods: Structured interviews were conducted with patients followed in a continuity care general medicine clinic at the Department of Veterans Affairs Medical Center, Portland, Oregon. Patients were asked to consider whether they would accept IVS at a future time. Patients were randomly assigned to one of two explanation conditions that differed in terms of their future medical contexts, that is, the degrees of specification of the nature of the medical condition patients were asked to consider. The general-explanation group was asked to consider the future medical context of " an unspecified medical condition"; the specific-explanation group was asked to consider the future medical context of "a severe pneumonia." Patients were asked three questions: 1) Would you accept IVS (yes or no)? 2) How long would you allow your physician to continue IVS?; and 3) After being on IVS for 2-3 days, what would be the minimum chance of recovery from the condition you would require before agreeing to continued IVS? "Chance of recovery" was defined for both groups as the probability that the patient would be able to leave the hospital and be able to take care of activities of daily living unassisted with minimal change in his or her mental state from the pre-hospitalization status., Results: Of 186 patients (mean age = 66.5 years; mean education = 12.7 years), 97 received the general explanation and 89 received the specific explanation about a severe pneumonia. Significantly fewer (p = 0.03) patients receiving the general explanation wanted physicians to intervene with IVS (general 94% vs specific 100%). Patients receiving the general explanation were willing to accept significantly fewer (p = 0.009) days of intubation (general 65 days vs specific 96 days). Significantly fewer (p < 0.0001) patients receiving the general explanation wanted physicians to continue IVS when the probability of a successful outcome was less than 50% (general 30% vs specific 64%)., Conclusion: Physician explanations--based on general (unspecified medical condition) vs specific (severe pneumonia) explanations--have a marked influence on the duration of IVS patients would permit and the probability of a good outcome required to continue IVS.

We designed this study to determine whether patients with early localized prostate cancer prefer surgical intervention over watchful waiting, which aspects of the 2 management strategies influence patient preferences, and whether there are patient characteristics that predict their preferences for 1 strategy over the other. Structured interviews were used with 140 male patients seen consecutively at a university-based Department of Veterans Affairs Medical Center outpatient clinic. The mean age of the patients was 66.3 years. Of the 140 patients, 53% preferred surgical treatment, 42% preferred observation, 4% preferred that their physician make the decision, and 1% preferred radiotherapy. Of 74 patients selecting surgical intervention, 92% (68) reported that the possibility of complete tumor removal was the strongest factor influencing their decision. Of those selecting observation, 80% (47/59) reported being most influenced by the complications of an operation. Older patients were significantly (P < .002) more likely to prefer expectant management. We conclude that tumor excision is an important factor influencing patient preferences for treatment, irrespective of survival benefits. This factor should be considered when designing approaches to providing information to patients about alternative treatments.

Objective: To determine whether an intervention designed to improve patient-physician communication increases the frequency with which physicians elicit patients' concerns, changes other communication behaviors, and improves health care outcomes., Design: Pretest-posttest design with random assignment of physicians to intervention or control groups., Setting: General medicine clinics of a university-affiliated Veterans Affairs Hospital., Patients/participants: Forty-two physicians and 348 continuity care patients taking prescription medications for chronic medical conditions., Interventions: Intervention group physicians received 4.5 hours of training on eliciting and responding to patients' concerns and requests, and their patients filled out the Patient Requests for Services Questionnaire prior to a subsequent clinic visit. Control group physicians received 4.5 hours of training in medical decision-making., Measurements and Main Results: The frequency with which physicians elicited all of a patient's concerns increased in the intervention group as compared with the control group (p = .032). Patients perceptions of the amount of information received from the physician did increase significantly (p < .05), but the actual magnitude of change was small. A measure of patient satisfaction with the physicians was high at baseline and also showed no significant change after the intervention. Likewise, the intervention was not associated with changes in patient compliance with medications or appointments, nor were there any effects on outpatient utilization., Conclusions: A low-intensity intervention changed physician behavior but had no effect on patient outcomes such as satisfaction, compliance, or utilization. Interventions may need to focus on physicians and patients to have the greatest effect.

Objective: To find out whether patients' preferences for a particular type of treatment are changed by the way in which the information is presented (point estimates-year 0 and year 5 data points-or two five-year survival curves)., Design: Prospective study., Setting: University-based Department of Veterans Affairs Medical Center, USA., Subjects: 236 Consecutive patients seen in a general medical outpatient clinic., Interventions: Patients were asked to choose between two treatments, one with a 10% immediate mortality and 37% five-year survival (treatment A) and one with no immediate mortality and 22% five-year survival (treatment B). They were randomised to be given the survival data either as point estimates or as two five-year survival curves., Main Outcome Measures: Number of patients who chose each treatment., Results: The mean age was 67 years (range 40-84) and mean duration of education was 13 years (range 0-22). Significantly fewer patients chose the treatment with better immediate survival when they were given the data as survival curves (47/140, 34% compared with 93/140, 66% p < 0.0001) than when they were given data as point estimates (57/96, 59%, compared with 39/96, 41%)., Conclusion: Patients are significantly more likely to make different decisions when given more data (in the form of five-year survival curves which show short, medium, and long term results) than when they are presented with only point estimates.

Study Objective: To assess patients' willingness to accept the risks of intubation and ventilatory support (IVS) for short periods of time., Design: Cross-sectional structured interviews of patients., Setting: The Department of Veterans Affairs Medical Center, Portland, Oregon, USA, a university-based Department of Veterans Affairs Medical Center., Participants: 97 consecutive patients (mean age =67.4 years, s.d. =9.16, range =39-84) seen for continuity clinic appointments in a general medicine clinic., Measurements and Results: In a hypothetical situation of an acute exacerbation of a medical condition requiring IVS, patients were asked whether they would accept IVS if their physician thought that their acute exacerbation was reversible (defined as being able to leave the hospital with their mental capacity minimally affected and being able to care for themselves in most activities of daily living in a nursing home environment). Patients were also asked to define what they meant by a "short period of time of IVS," and at what chance of reversal of their acute exacerbation they would allow their physicians to act with IVS (measured by means of a lottery methodology). Ninety-seven percent (94/97) of patients reported a willingness to undergo IVS for a short period of time. Eighteen percent reported that they would allow IVS for 1-2 days; 38% reported 3-14 days; 14% reported 15-30 days; and 30% reported >30 days. One third of the patients were willing to accept IVS if the probability of reversal were ≤40%. Patients with advance directives preferred to be supported for fewer days on IVS than patients without an advance directive (P=0.014)., Conclusions: We conclude that most patients are willing to allow IVS for the reversal of an acute condition as defined above. There are wide variations in the length of time patients would allow IVS and in the probability of reversal they would require before their physician intervened with IVS on their behalf. These results suggest that discussions about advance directives with patients should include assessment of patient preferences about duration of intervention and probability of successful outcome.

Objective: To evaluate the influence of physicians' explanations on patients' choices., Setting: A university-based Department of Veterans Affairs Medical Center., Participants: 136 patients seen in a continuity-care general medicine clinic., Measurements and Results: Patients were randomized to two groups [Limited Explanation (LE) and Extensive Explanation (EE)] and asked to choose between two alternative treatments (differing in short-term vs long-term survival benefits) for an unidentified medical condition, based on the information given in the explanations. LE consisted of a brief orientation to graphs summarizing the treatment results, while EE consisted of a detailed verbal description of the graphs. Significantly (p < 0.001) more patients receiving EE changed their preferences across the three pairs of five-year survival curves, compared with patients receiving LE. Of the patients receiving EE, 57% reported either medium-term (year 0-to-intercept or intercept-to-year 5) data or the average life expectancy for the five-year period contained in the curves (ALE-5) as most influencing their decision making; whereas 78% of patients receiving LE reported only endpoint (year 0 or year 5) data as most influencing their preferences., Conclusions: The patients' treatment preferences for long-term vs short-term survival benefits were influenced by the amounts of verbal explanation provided to them about five-year survival graphs summarizing treatment results. The patients appeared to minimize the importance of medium-range data when those data were not specifically pointed out to them.

Continual rotation of house officers builds discontinuity into the physician-patient relationship in teaching hospitals. This has led to speculation about the problem of residents and interns leaving their patients in the midst of hospital treatment. This article uses prospective data to assess the effect of house officer turnover on levels of patient satisfaction with hospital care and on patient perception of the hospital environment. Two inpatient cohorts defined by whether or not they had undergone a house officer change were matched by age and diagnostic category. Although survey instruments were significantly correlated, there was no significant difference between the two inpatient cohorts overall or on any of the survey subscales. The survey showed good satisfaction with the hospital, doctors, and nurses in both test groups. The authors draw a preliminary conclusion that patient satisfaction with medical care and with the hospital atmosphere remains constant, independent of termination of the doctor-patient relationship. Results from other reports linking patient satisfaction with continuity of care have been mixed. In discussing the limitations of their study, the authors point out that their findings are based on single-site data.

Study Objectives: Recent research has brought into question patients willingness to accept immediate treatment risk for the possibility of increased 5-year survival. This study was designed to assess whether patients are able to identify the probability of initial mortality they would be willing to accept in order to increase their chance of long-term survival., Design: Cross-sectional structured interviews with continuity clinic patients., Setting: A university-based Department of Veterans Affairs Medical Center general medicine clinic., Participants: 128 consecutive patients (mean age = 65.4 years (s.d. = 11.27, range of ages = 30-83)), seen in the second half of 1992., Measurements and Results: In a hypothetical setting, patients were presented with a pair of curves representing expected survival over a 5-year period for I two alternative treatments. The disease and treatments were not identified. In one curve, there was a 10% peri treatment mortality rate and a 37% 5-year survival; in the second curve, there was a 0% peritreatment mortality rate and a 22% 5-year survival. Once patients selected the treatment they preferred based on the curve pair, they were asked whether they were willing to accept an initial risk higher than the one they had selected. Of the 128 patients, 26.6% (34/128) selected the treatment with a 0% mortality in the peritreatment period. For these 34 patients, their mean initial acceptable probability of death was 3.75% (s.d. = 2.32, range 0-9). Of the 94 study patients who selected the 5-year curve with 10% mortality in the peritreatment period, the mean initial risk they were willing to accept was 14.73% (s.d. = 9.12, range = 10-70). Older patients were less willing than younger patients to accept probabilities at higher than the given immediate peritreatment risks for both treatments (chi square = 4.330, d.f. = 1, P < 0.04)., Conclusions: Patients are not as uncomfortable at taking immediate risks of death for a 5-year survival benefit. Patients report a willingness to accept risk of immediate death for 5-year survival benefits.

All of the methods currently used to assess information retrieval (IR) systems have limitations in their ability to measure how well users are able to acquire information. We utilized a new approach to assessing information obtained, based on a short-answer test given to senior medical students. Students took the ten-question test and then searched one of two IR systems on the five questions for which they were least certain of their answer Our results showed that pre-searching scores on the test were low but that searching yielded a high proportion of answers with both systems. These methods are able to measure information obtained, and will be used in subsequent studies to assess differences among IR systems.

Most patients have explicit desires or requests when they visit their physicians. Identification of patients' requests and needs is the starting point of a patient-centered approach to care. The frequency with which physicians met their patients' desires for services and that frequency's association with patient satisfaction were examined for 243 patients with chronic disease in general medicine clinics of a Department of Veterans Affairs hospital. Patients desired a mean of 11.9 services, of which an average of 67 percent were met. However, many patients' desires for information and most of their desires for help with emotional and family problems were not met. Patients with the most unmet desires for services, especially services related to information, were significantly less satisfied with their physicians than were those with fewer unmet desires. Factor analysis was used to develop a short, 16-item Requests for Services Questionnaire that appeared to cover the range of services that patients with chronic conditions desire. Enhancing physicians' ability to recognize and respond to patients' desires for services by using short patient request questionnaires may have the potential to improve patient satisfaction and other health care outcomes.

The objective of this study was to compare how well medical professionals are able to retrieve relevant literature references using two computerized literature searching systems that provide automated (non-human) indexing of content. The first program was SAPHIRE, which features concept-based indexing, free-text input of queries, and ranking of retrieved references for relevance. The second program was SWORD, which provides single-word searching using Boolean operators (AND, OR). Sixteen fourth-year medical students participated in the study. The database for searching was six volumes from the 1989 Yearbook series. The queries were ten questions generated on teaching rounds. All subjects searched half the queries with each program. After the searching, each subject was given a questionnaire about prior experience and preferences about the two programs. Recall (proportion of relevant articles retrieved from the database) and precision (proportion of relevant articles in the retrieved set) were measured for each search done by each participant. Mean recall was 57.6% with SAPHIRE; it was 58.6% with SWORD. Precision was 48.1% with SAPHIRE vs 57.6% with SWORD. Each program was rated easier to use than the other by half of the searchers, and preferences were associated with better searching performance for that program. Both systems achieved recall and precision comparable to existing systems and may represent effective alternatives to MEDLINE and other retrieval systems based on human indexing for searching medical literature.

Objective: To assess outpatients' attitudes toward and understanding of a standard living will., Design: Survey using a self-administered questionnaire that patients completed after they had read a sample living will., Setting: General medicine clinic of a Department of Veterans Affairs medical center., Patients: Two hundred fourteen patients (85% of those approached) attending a continuity care clinic appointment. Eighty-seven percent were men; mean age was 60 years., Measurements and Main Results: Patients' attitudes toward living wills, understanding of the terminology contained in living wills, desire to discuss living wills with their doctors, and desire to prepare a living will., Results: Seventy-two percent of the patients had prior knowledge of living wills, though only 53% had discussed the topic with family members and only 14% with physicians. Half felt that the living will terminology should be simplified, and 55% were unable to identify the correct definition for at least one commonly used term. Desire to prepare a living will was positively associated with better understanding of the sample document and previous knowledge of and exposure to living wills, and was negatively associated with concern about its use and revocability (all p < 0.001). Patients who reported poor understanding of the living will were more likely to want to discuss the topic with a physician (p < 0.01)., Conclusions: In this ambulatory patient population attitudes toward living wills were influenced by knowledge and understanding of these documents. Primary care physicians and institutions should develop patient education strategies that enhance understanding of advance directives.

To assess how patients' and physicians' treatment preferences are influenced by graphic data displays (five-year survival curves), a cross-sectional survey of patients, physicians, and medical students was done in a university-based Department of Veterans Affairs Medical Center. Participants in the study were 119 patients seen in a general medicine clinic, 43 physicians, and 67 medical students. Three five-year survival graphs were used. Each graph contained survival curves for two alternative unidentified treatments for an unidentified medical condition. Graph 1 was a baseline graph used in previous studies of framing effects. Graph 2 contained one survival curve having an area under the curve that was 24% greater than that in graph 1. Graph 3 contained one survival curve that had an area under the curve that was 42% greater than that in graph 1. Respondents were asked to indicate which treatment they preferred for each graph and which aspects of the five-year survival curves most influenced their choices. Respondents did not receive numerical data about the difference between the areas under the two curves. Most patients did not change their preferences across the three graphs. A significantly larger (p < or = 0.0001) proportion of physicians and medical students than of patients changed their preferences across the three graphs.(ABSTRACT TRUNCATED AT 250 WORDS)

Conventional approaches to indexing medical literature include the human assignment of terms from a controlled vocabulary, such as MeSH, or the computer assignment of all words in the title and abstract as indexing terms. Human indexing suffers from inconsistency, while word-based indexing suffers from the multiple meanings of words. SAPHIRE is a computer program designed to provide indexing using controlled terms that are assigned by computer, based on their occurrence in the title and abstract. In this first evaluation of SAPHIRE, the authors compared the retrieval performance of the three indexing approaches--human-based MEDLINE with text words; machine-based SAPHIRE with text words; and text words only--for searches by measuring recall and precision for each search using a test collection of 200 abstracts. The abstracts were judged by human reviewers for relevance as applied to 12 literature queries. The results suggest that text word indexing is more effective than indexing with MeSH terms. SAPHIRE's indexing performance was slightly inferior but the program has other advantageous features.

What is the best way to represent the content of documents in an information retrieval system? This study compares the retrieval effectiveness of five different methods for automated (machine-assigned) indexing using three test collections. The consistently best methods are those that use indexing based on the words that occur in the available text of each document. Methods used to map text into concepts from a controlled vocabulary showed no advantage over the word-based methods. This study also looked at an approach to relevance feedback which showed benefit for both word-based and concept-based methods.