ITEMS IN AFP WITH MESH TERM:
Breaking Bad News - Article
ABSTRACT: Breaking bad news is one of a physician's most difficult duties, yet medical education typically offers little formal preparation for this daunting task. Without proper training, the discomfort and uncertainty associated with breaking bad news may lead physicians to emotionally disengage from patients. Numerous study results show that patients generally desire frank and empathetic disclosure of a terminal diagnosis or other bad news. Focused training in communication skills and techniques to facilitate breaking bad news has been demonstrated to improve patient satisfaction and physician comfort. Physicians can build on the following simple mnemonic, ABCDE, to provide hope and healing to patients receiving bad news: Advance preparation--arrange adequate time and privacy, confirm medical facts, review relevant clinical data, and emotionally prepare for the encounter. Building a therapeutic relationship-identify patient preferences regarding the disclosure of bad news. Communicating well-determine the patient's knowledge and understanding of the situation, proceed at the patient's pace, avoid medical jargon or euphemisms, allow for silence and tears, and answer questions. Dealing with patient and family reactions-assess and respond to emotional reactions and empathize with the patient. Encouraging/validating emotions--offer realistic hope based on the patient's goals and deal with your own needs.
ABSTRACT: Family physicians must proactively address the sexual health of their patients. Effective sexual health care should address wellness considerations in addition to infections, contraception, and sexual dysfunction. However, physicians consistently underestimate the prevalence of sexual concerns in their patients. By allocating time to discuss sexual health during office visits, high-risk sexual behaviors that can cause sexually transmitted diseases, unintended pregnancies, and unhealthy sexual decisions may be reduced. Developing a routine way to elicit the patient's sexual history that avoids judgmental attitudes and asks the patient for permission to discuss sexual function will make it easier to gather the necessary information. Successful integration of sexual health care into family practice can decrease morbidity and mortality, and enhance well-being and longevity in the patient.
ABSTRACT: Family physicians should take advantage of each contact with smokers to encourage and support smoking cessation. Once a patient is identified as a smoker, tools are available to assess readiness for change. Using motivational interviewing techniques, the physician can help the patient move from the precontemplation stage through the contemplation stage to the preparation stage, where plans are made for the initiation of nicotine replacement and/or bupropion therapy when indicated. Continued motivational techniques and support are needed in the action stage, when the patient stops smoking. Group or individual behavioral counseling can facilitate smoking cessation and improve quit rates. Combined use of behavioral and drug therapies can dramatically improve the patient's chance of quitting smoking. A plan should be in place for recycling the patient through the appropriate stages if relapse should occur.
ABSTRACT: Childhood bullying has potentially serious implications for bullies and their targets. Bullying involves a pattern of repeated aggression, a deliberate intent to harm or disturb a victim despite the victim's apparent distress, and a real or perceived imbalance of power. Bullying can lead to serious academic, social, emotional, and legal problems. Studies of successful antibullying programs suggest that a comprehensive approach in schools can change student behaviors and attitudes, and increase adults' willingness to intervene. Efforts to prevent bullying must address individual, familial, and community risk factors, as well as promote an understanding of the severity of the problem. Parents, teachers, and health care professionals must become more adept at identifying possible victims and bullies. Physicians have important roles in identifying at-risk patients, screening for psychiatric comorbidities, counseling families about the problem, and advocating for bullying prevention in their communities.
ABSTRACT: Men who have sex with men often do not reveal their sexual practices or sexual orientation to their physician. Lack of disclosure from the patient, discomfort or inadequate training of the physician, perceived or real hostility from medical staff, and insufficient screening guidelines limit preventive care. Because of greater societal stresses, lack of emotional support, and practice of unsafe sex, men who have sex with men are at increased risk for sexually transmitted diseases (including human immunodeficiency virus infection), anal cancer, psychologic and behavioral disorders, drug abuse, and eating disorders. Recent trends indicate an increasing rate of sexual risk-taking among these men, particularly if they are young. Periodic screening should include a yearly health risk and physical assessment as well as a thorough sexual and psychologic history. The physician should ask questions about sexual orientation in a nonjudgmental manner; furthermore, confidentiality should be addressed and maintained. Office practices and staff should be similarly nonjudgmental, with confidentiality maintained. Targeted screening for sexually transmitted diseases, depression, substance abuse, and other disorders should be performed routinely. Screening guidelines, while inconsistent and subject to change, offer some useful suggestions for the care of men who have sex with men.
ABSTRACT: Support of patient self-management is a key component of effective chronic illness care and improved patient outcomes. Self-management support goes beyond traditional knowledge-based patient education to include processes that develop patient problem-solving skills, improve self-efficacy, and support application of knowledge in real-life situations that matter to patients. This approach also encompasses system-focused changes in the primary care environment. Family physicians can support patient self-management by structuring patient-physician interactions to identify problems from the patient perspective, making office environment changes that remove self-management barriers, and providing education individually and through available community self-management resources. The emerging evidence supports the implementation of practice strategies that are conducive to patient self-management and improved patient outcomes among chronically ill patients.
ABSTRACT: Controversy surrounds the management options for localized prostate cancer-conservative management, prostatectomy, and radiation. Choosing among these options is difficult because of long-term side effects that include sexual, urinary, and bowel dysfunction. Some recent studies suggest that patients who have chosen treatment (i.e., radical prostatectomy or radiation) have longer disease-free survival compared with patients who have chosen conservative management (i.e., watchful waiting). However, several biases may artificially enhance the perceived value of treatment and make the interpretation of studies on treatment outcomes difficult. Sources of bias include lead time, length time, and patient selection. Because of the uncertain efficacy of management options and the risk of long-term treatment complications, family physicians need to engage their patients in the decision-making process.
Management of the Difficult Patient - Article
ABSTRACT: All physicians must care for some patients who are perceived as difficult because of behavioral or emotional aspects that affect their care. Difficulties may be traced to patient, physician, or health care system factors. Patient factors include psychiatric disorders, personality disorders, and subclinical behavior traits. Physician factors include overwork, poor communication skills, low level of experience, and discomfort with uncertainty. Health care system factors include productivity pressures, changes in health care financing, fragmentation of visits, and the availability of outside information sources that challenge the physician's authority. Patients should be assessed carefully for untreated psychopathology. Physicians should seek professional care or support from peers. Specific communication techniques and greater patient involvement in the process of care may enhance the relationship.
ABSTRACT: Patients with personality disorders are common in primary care settings; caring for them can be difficult and frustrating. The characteristics of these patients' personalities tend to elicit strong feelings in physicians, lead to the development of problematic physician-patient relationships, and complicate the task of diagnosing and managing medical and psychiatric disorders. These chronic, inflexible styles of perceiving oneself and interacting with others vary widely in presentation. In the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., these styles are categorized into three clusters based on their prominent characteristics: cluster A, the odd or eccentric (e.g., paranoid, schizoid, schizotypal); cluster B, the dramatic, emotional, or erratic (e.g., antisocial, borderline, histrionic, narcissistic); and cluster C, the anxious or fearful (e.g., avoidant, dependent, obsessive-compulsive). Knowledge of the core characteristics of these disorders allows physicians to recognize, diagnose, and treat affected patients. The goal of management is to develop a working relationship with patients to help them receive the best possible care despite their chronic difficulties in interacting with physicians and the health care system. Effective interpersonal management strategies exist for these patients. These strategies vary depending on the specific diagnosis, and include interventions such as the use of specific communication styles, the establishment of clear boundaries, limit setting on the patients' behavior and use of medical resources, and provision of reassurance when appropriate. Additionally, medications may be useful in treating specific symptoms in some patients.
ABSTRACT: Ethnic minorities currently compose approximately one third of the population of the United States. The U.S. model of health care, which values autonomy in medical decision making, is not easily applied to members of some racial or ethnic groups. Cultural factors strongly influence patients' reactions to serious illness and decisions about end-of-life care. Research has identified three basic dimensions in end-of-life treatment that vary culturally: communication of "bad news"; locus of decision making; and attitudes toward advance directives and end-of-life care. In contrast to the emphasis on "truth telling" in the United States, it is not uncommon for health care professionals outside the United States to conceal serious diagnoses from patients, because disclosure of serious illness may be viewed as disrespectful, impolite, or even harmful to the patient. Similarly, with regard to decision making, the U.S. emphasis on patient autonomy may contrast with preferences for more family-based, physician-based, or shared physician- and family-based decision making among some cultures. Finally, survey data suggest lower rates of advance directive completion among patients of specific ethnic backgrounds, which may reflect distrust of the U.S. health care system, current health care disparities, cultural perspectives on death and suffering, and family dynamics. By paying attention to the patient's values, spirituality, and relationship dynamics, the family physician can elicit and follow cultural preferences.