The physician's influence on informed consent for bone marrow transplantation

The influence of physician judgment on the disclosure, competency, understanding, voluntariness, and decision aspects of informed consent for bone marrow transplantation are described. Ethical conflicts which arise from the amount and complexity of the information to be disclosed and from the barriers of limited time, patient anxiety and lack of prior relationship between patient and physician are discussed. The role of the referring physician in the decision-making is considered. Special ethical issues which arise with use of healthy related bone marrow donors are discussed, as is the physician's discretion in raising questions of competency. It is concluded that in this setting, regardless of the theoretical goals of the physician, patients appear to utilize informed consent discussions to assess their capacity to trust the physician rather than as a time to weigh the large amount of relevant data. The conscientious physician best serves the patient with recommendation of the best medical alternative rather than with attempts to remain neutral.     

Attachment, sleep quality, and depressed affect.

This study examined the role of attachment insecurity in sleep problems among married adults (N=78 couples). Using the Pittsburgh Sleep Quality Index and structural equation modeling, attachment anxiety was associated with higher levels of self-reported sleep difficulties for men and women, whereas attachment avoidance was not. Depressed affect was included as a control variable, and the effect of attachment anxiety remained significant. Men and women did not differ significantly in the magnitude of the effect of attachment anxiety on sleep quality. In addition, there were no cross-partner effects of attachment insecurity on sleep quality or depressed affect. Implications and future directions are discussed.     

Lymphocyte subsets, cardiovascular measures and anxiety state before and after a professional examination

Controversies exist regarding the impact of psychological stress on the functioning of the immune system in humans. The aim of the present study, therefore, was to evaluate whether the condition of a pre-exam stress may or not modify resting lymphocyte subsets, as well as blood pressure and heart rate. About 22 medical residents of both sexes not suffering from any medical or psychiatric disorder were included in the study. Anxiety levels were measured by means of the Hamilton rating scale for anxiety (HRSA) and anxiety traits by means of the panic-agoraphobic spectrum self-report (PAS-SR) version and the obsessive-compulsive spectrum self-report (OBS-SR) version. The results showed that systolic blood pressure and heart rate increased significantly just before sitting an examination (t(1)) in all subjects, as compared with a calm situation (t(2)), in parallel with the increase in the HRSA total score, while no significant difference was observed in lymphocyte subsets at the two assessment times. However, men had a higher number of CD4+ cells than women at t(1) and t(2), while women showed a higher heart rate at t(1). In addition, significant correlations between CD4+ lymphocyte count and heart rate at t(1) or HRSA at t(2) were detected. These findings indicate that the acute stress determined by sitting for examination provokes changes in autonomic nervous system parameters, such as blood pressure and heart rate, as well as in the subjective feeling of anxiety, as shown by the increased HRSA total scores, which were not paralleled by modifications of lymphocyte subsets. However, individual differences, related to both sex and personality traits yet to be identified, seem to have an impact in shaping the stress response.     

"Trust me...": psychological and behavioral predictors of perceived physician empathy

A sociocognitive model of distal and proximal predictors of empathic judgments was tested among 100 physicians. The authors hypothesized that physician perceived control would affect empathy ratings via physician communication style. Specifically, physicians with high perceived control would use more open communication and be rated as more empathic. Physicians with low perceived control would use a controlling communication style and be rated as less empathic. Physicians completed a medical attribution questionnaire prior to a structured patient consultation exercise, during which patients and assessors rated physician empathy. The exercise was audiotaped, transcribed, and content analyzed for verbal behaviors. Support was found for the hypotheses; however, patients, but not medical assessors, associated empathy with reassurance and provision of medical information.     

Postmodernist theory and the physician-patient relationship

The author discusses the postmodernist claim that the grand theories have lost credibility, even in the field of medical science and practice. Rather than representing a shared reality among physician and patient, illness represents two quite distinct realities — the meaning of one being significantly and distinctively different from the meaning of the other. However, existential clinical narratives can function as important bridges between the world of the patient and the world of the physician. Such narratives provide important information regarding the patient's biographical situation and, particularly, the personal and cultural meanings which are a function of the biographical situation. At the same time, these narratives provide physicians with useful information for the practice of medicine.     

In Pursuit of the MD: The Impact of Role Models, Identity Compatibility, and Belonging Among Undergraduate Women

Women continue to face gender-related challenges in the medical field in places around the world where it has traditionally been male-dominated, including in the U.S. In an online experimental study with women attending a mid-sized public university in the Northeastern U.S. (N?=?55) who were interested in pursuing a pre-medical track (being pre-med) as undergraduates, we explored the mechanisms involved in undergraduate women’s pursuit of a career as a physician, focusing on three factors: exposure to successful female physician role models, perceived identity compatibility between being a woman and being pre-med, and sense of belonging in pre-med. Participants were randomly assigned to an experimental condition in which they were exposed to information about successful female physicians, or to a control condition in which no information about female physicians was provided. First, as hypothesized, participants exposed to successful female physicians reported higher perceived identity compatibility, sense of belonging, and interest in a medical career compared to those in the control condition. Second, also as hypothesized, perceived identity compatibility mediated the effect of role models on sense of belonging, and sense of belonging mediated the relationship between perceived identity compatibility and interest in a medical career. This study highlights three key factors in women’s pursuit of a career as a physician and the process through which these factors may operate. Findings support the use of role models to set a positive psychosocial process in motion that can support women’s persistence in medicine.     

Criminal victimization among primary care medical patients: prevalence, incidence, and physician usage

The study addressed the extent to which primary care physicians encounter crime victims in their practices. Crime prevalence and incidence rates were calculated from responses to a mailed survey of 2,291 women medical patients (45% response rate). The prevalence of crime victimization was 57%. The 12 month incidence of violent crime was 118 per 1,000 patients. Most notable was the finding that rape incidence was approximately 15 times higher than National Crime Survey estimates for women, even after adjustment for telescoping. Post-crime physician usage was documented by medical chart review. Although few crime victims required hospitalization for injuries, virtually all made out-patient physician visits in each of two post-crime years. The findings suggest that physicians are an important potential source of assistance for traumatized crime victims.     

Decision Making with Uncertain Information: Learning from Women in a High Risk Breast Cancer Clinic

Patients and practitioners may believe that clinically validated laboratory tests provide definitive information. Genetic counselors know this is not always so, and the possibility of inconclusive genetic test results is often discussed in the pretest counseling session. This added discussion topic prolongs the process of genetic counseling, but if there is inadequate patient understanding, patient frustration may be high when receiving a result of uncertain significance, and patients may make decisions about subsequent medical management based on incorrect assumptions. For patients/participants in a research setting, where the clinical validity of testing may be unclear, some patients/participants may still want to use test results to influence their medical management. This paper presents findings from a qualitative study wherein 15 women from the High Risk Breast Cancer Clinic at Utah's Huntsman Cancer Institute discussed how uncertainty regarding results affected their decision making. The women were randomly selected from 3 categories--women with test results of uncertain significance; women without cancer who have a mutation; and women who are members of high-risk families, but for whom no mutation was found. Study findings will be used in future studies to better understand how to improve communication regarding uncertain results, especially in a research environment.     

Anxiety and cancer treatment: response to stressful radiotherapy

Previous research with individuals undergoing surgery or diagnostic procedures provided a conceptual framework for analysis of radiation therapy, a common form of cancer treatment. The present investigation was designed to document the magnitude of anxiety patients experience in response to one particularly stressful form of radiation treatment. In addition, the change in anxiety responses with repeated exposures and individual differences among patients that may affect their adjustment were explored. In Part 1, gynecologic cancer patients receiving their first internal radiotherapy application were studied. As the time for treatment neared, subjective and physiologic indicants of anxiety and distress among the patients significantly increased. By 24 hours post-treatment, anxiety for all patients remained elevated. These post-treatment data are convergent with other investigations of post-treatment distress among cancer patients, but contrast with data obtained from those receiving treatment for benign conditions. A subset of the women who required two applications of radiotherapy participated in Part 2. These patients continued to respond negatively during the second treatment. Data on individual differences in anxiety responses (i.e., low vs. high anxiety) were obtained in both investigations and suggest that those with low levels of pre-treatment anxiety experience considerable disruption post-treatment.     

Delays in seeking cancer diagnosis in relation to beliefs about the curability of cancer in patients with different disease locations

This study is aimed at investigating factors leading to delayed oncologic examinations versus immediate consultation with a physician in patients with various cancers. We analysed the results of a study of patients (n?=?291) reporting for their first oncologic examinations. We conducted structured interviews containing social, demographic and clinical data, the Spielberger State-Trait Anxiety Inventory, the Beck Depression Inventory and Harris and Guten's health appraisal scores. Based on an analysis of decision-making trees, the results indicate that it is possible to predict beliefs regarding the curability of cancer and immediate versus delayed reporting to a physician. Delayed reports may be predicted on the basis of two factors: (1) a belief that cancer is incurable combined with increased state anxiety, ‘good’ or ‘very good’ self-appraisal of health and low depression; and (2) a belief that cancer is incurable accompanied by increased anxiety and depression. The characteristics of patients delaying a visit to the oncologist suggest the existence of three independent factors leading to both considerable (longer than nine months) and minor (up to one month) delays in seeking treatment.     

Patient-oriented interventions to improve communication in a medical office visit

Examined a simple intervention to improve the patient's contribution to communication in a medical office visit. In the first study, women awaiting a medical appointment were randomly assigned either to a group that was asked to list three questions to ask their physician or to a control group. Women who listed questions asked more questions in the visit and reported being less anxious. In the second study, a third group that received a message from their physician encouraging question asking was added. Both experimental groups asked more of the questions they had wished to, had greater feelings of control, and were more satisfied with the visit in general and with the information they received. The two experimental groups did not differ significantly, suggesting that the effect may be attributed either to thinking one's questions out ahead of time or to the perception that one's physician is open to questions.     

Psychological side effects of breast cancer screening

Evaluated the impact of receiving abnormal mammogram results on women's anxiety and breast cancer worries and on their breast self-examination (BSE) frequency and intentions to obtain subsequent mammograms. A telephone survey was conducted with 308 women 50 years old and older approximately 3 months following a screening mammogram. Subjects included women with suspicious abnormal mammograms, nonsuspicious abnormal mammograms, and normal mammograms. Women with suspicious abnormal mammograms exhibited significantly elevated levels of mammography-related anxiety and breast cancer worries that interfered with their moods and functioning, despite the fact that diagnostic work-ups had ruled out breast cancer. Women with moderate levels of impairment in mood or functioning were more likely to practice monthly BSE than women with either high or low levels of impairment. Breast cancer worries, perceived susceptibility to breast cancer, and physician encouragement to get mammograms all exhibited independent positive relationships to mammogram intentions.     

Prenatal and postnatal anxiety in Mexican women giving birth in Los Angeles

Examined psychosocial factors related to prenatal and postnatal anxiety in 291 primiparous Mexican women giving birth in Los Angeles. Characteristics of health care providers preferred by more anxious and less anxious women were also assessed. Higher prenatal anxiety was associated with less desire for an active role during labor, lower assertiveness, higher pain expectation at delivery, lack of support from family members other than the husband, and preferences for health care providers who are female and Latino. All groups of women preferred health care providers who provided good medical explanations and who were knowledgeable, friendly, and sympathetic. Postnatal anxiety was significantly lower than prenatal anxiety. Negative attitudes toward the baby and number of complications during labor and delivery, however, were related to postnatal anxiety adjusted for prenatal anxiety.     

Patients’ Characteristics Affecting Physician-Patient Nonverbal Communication

Previous research has reported that nonverbal elements of physician-patient communication influence medical outcomes such as patients’ understanding, compliance, and saris/action with health care delivery. This investigation examined the impact of various patients’ characteristics (age, sex, education, anxiety, and relational history with the physician) on patterns of nonverbal communication exhibited in 41 physician-patient interactions at a family practice clinic. Several findings were noteworthy. First, although they were relatively consistent in their nonverbal responses to different patients, physicians generally reciprocated patient's adjustments in response latency, pauses during speaking turns, body orientation, and interruptions and compensated patient's modifications in turn duration and gestural rates. Second, physicians nonverbally interacted with patients over 30 years of age in a less domineering and more responsive fashion (e.g., comparable turn durations, more vocal back-channels, and more nonverbal behavior reciprocity) than they did when conversing with patients under 30. Third, physicians appeared responsive to patients experiencing various degrees of anxiety. Specifically, relative to their interactions with less worried patients, physicians used less task touch with anxious patients and to a greater degree compensated the worried patients nonverbal responses. Finally, the patients sex, education, and visit (i.e., first versus repeat) had little impact on the structure of physician-patient nonverbal exchanges.     

Mental health measurement among women veterans receiving co-located,collaborative care services

Routine use of measurement to identify patient concerns and track treatment progress is critical to high quality patient care. This is particularly relevant to the Primary Care Behavioral Health model, where rapid symptom assessment and effective referral management are critical to sustaining population-based care. However, research suggests that women who receive treatment in co-located collaborative care settings utilizing the PCBH model are less likely to be assessed with standard measures than men in these settings. The current study utilized regional retrospective data obtained from the Veterans Health Administration’s electronic medical record system to: (1) explore rates of mental health measurement for women receiving co-located collaborative care services (N = 1008); and (2) to identify predictors of mental health measurement in women veterans in these settings. Overall, only 8% of women had documentation of standard mental health measures. Measurement was predicted by diagnosis, facility size, length of care episode and care setting. Specifically, women diagnosed with depression were less likely than those with anxiety disorders to have standard mental health measurement documented. Several suggestions are offered to increase the quality of mental health care for women through regular use of measurement in integrated care settings.     

Unemployment, coping and psychological distress

This study addressed the role of coping sytle in anxiety and depression of unemployed people. Two-hundred thirty-three people checking in at unemployment services participated. They filled in Carver, Scheier and Weintraub's (1989) coping measure (COPE), the Hospital Anxiety and Depression scale (HAD), gave information as to age, duration of unemployment and their appraisal of their situation. Four secondary dimensions of COPE were used in data analyses. Multiple regression analyses were undertaken with anxiety/depression as dependent and the coping variables as independent variables, with background/appraisal variables entered first. Coping variables added to the prediction of anxiety and depression over and above background/appraisal variables. For women Focus on Emotion coping as well as Avoidance was related to higher anxiety/depression scores ( p <0.01), whereas Reappraisal was related to lower anxiety/depression ( p <0.05). For men only Avoidance was related to anxiety/depression ( p <0.01). More Avoidance co-occurred with higher levels of anxiety as well as depression. The results are discussed with respect to possible intervention.     

Psychosocial Barriers to Cervical Cancer Screening: Concerns With Self-presentation and Social Evaluation1

The incidence of cervical cancer has decreased over 70% in the last several decades due in large part to the Papanicolaou (Pap) test. Despite the acknowledged efficacy of this test, however, many women do not receive cervical screening. The present study investigated the contributions of individual differences in concerns with self-presentation and social evaluation to the prediction of intentions and behavior involving cervical screening. Eighty-two Caucasian women completed measures of social anxiety, physique anxiety, public and private self-consciousness, fear of negative evaluation, and self-esteem, in addition to questions assessing their knowledge and behavior regarding cervical screening. Social anxiety significantly predicted intention to receive cervical screening for a medical reason, as well as the frequency with which the women actually received gynecological examinations. Physique anxiety accounted for a significant percentage of the variance in women's likelihood of receiving cervical screening within the next year. Interpersonal aspects of the gynecological exam, as well as implications of the findings for gynecological practice are discussed.     

TO BE FEMALE, MIDDLE CLASS, ANXIOUS, AND BLACK

Women of color theorists have suggested that the double minority status of gender and ethnicity places African American women at higher risk for anxiety. However, little information is available about anxiety disorders among African American women. The existing literature subsumes Black women under the general category of African Americans and focuses on low-income samples. In this study, we examine the manifestation of panic disorder in a sample of 15 predominantly middle-class African American women. We then compare these women to a group of 35 predominantly middle-class African American women without panic disorder on several factors, including presence of isolated sleep paralysis, presence of other anxiety disorders, help-seeking behavior, and victimization. Results indicate that African American women with panic disorder experienced isolated sleep paralysis, and that both groups had high levels of sexual victimization. Help-seeking among women with panic and other anxiety disorders was limited to relationship difficulties, sexual assault, and bereavement.     

Relation of depression and anxiety to personal and academic problems among Iranian college students

This study investigated the role of anxiety and depression in students' adjustment to family and campus life. The Cognition Checklist and a problem questionnaire were given to 1,452 college students (998 men, 454 women). Analysis showed that off-campus students were significantly less depressed and anxious. These college students were worried about jobs and marriage. Feelings of anxiousness and worry were reported; sex differences on depression scores were not significant.