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This paper reports the qualitative data from a study of sexual harassment of female family physicians by patients. In addition to the everyday harassment that any woman might encounter in a work setting, the physicians in this study also reported types of harassment which are unique to the practice of medicine. These include opportunistic harassment such as exposure of the genitals, inappropriately touching the physician when the examination requires close contact, excessive discussion of sexual matters for apparent erotic gratification, and acting out behaviours from non-competent patients. Other reported behaviours were not, strictly speaking, sexual harassment but were troublesome nonetheless, including spontaneous erections during physical examinations, physically intimidating behaviour, and ambiguous behaviours which were sexual in nature, but difficult to interpret. The findings are discussed in the context of theory pertaining to contrapower harassment. It is concluded that for some patients the gender of the physician takes precedence over her occupational status and, this combined with the unique characteristics of the doctor/patient relationship, can make the practice of family medicine more conducive to sexual harassment than other professions. Key words - female physicians, sexual harassment, contrapower harassment

Patients suffering from Munchausen syndrome will do everything in their power to provide basis for their complaints. A surgeon's encounter with a Munchausen patient supports this claim. The patient saw the surgeon for an apparent obstruction of bowel movement. However, surgery was not considered an option since her condition improved after every visit. The consistent complaining of the patient drew suspicion from the physician. After checking with the patient's previous doctors, it was found out that the patient deliberately altered her medical records to receive surgical treatment., Spotting this syndrome has gotten tougher, the author says. The new twist? Now patients can "document" their hoax. When patients reveal their symptoms and complaints to us, we assume they're [...]

Forty-six patients with spider phobia, fulfilling the DSM-IV criteria for specific phobia, were assessed with behavioral, physiological and self-report measures. They were randomly assigned to three group treatment conditions: (1) direct treatment; (2) direct observation; and (3) indirect observation. All treatments were carried out in large groups of eight patients, and consisted of one 3 hr session of massed exposure and modelling. The results showed that on the behavioral test, measures and the specific self-report measures of spider phobia the direct treatment was significantly better than direct observation and indirect observation, which did not differ. On the physiological measures and the psychopathology self-report measures there were significant pre-post improvements, but no differences between the groups. The effects were maintained or furthered at the one year follow-up assessment. The proportion of clinically significantly improved patients were, at post-treatment, 75% in the direct treatment, 7% in the direct observation, and 31% in the indirect observation group. At follow-up, the corresponding figures were 75, 14, and 44%, respectively. The conclusion that can be drawn is that direct treatment is the treatment of choice.

There are many problems with the current methods used to measure quality of life. Many questionnaires have been developed but they were designed by physicians and social scientists. Consequently, they may not focus on patients' concerns. Physicians sometimes believe that all patients should aspire to the same quality of life. The Quality-Adjusted Life Year (QALY) was devised to ensure that all medical treatments could be assessed by the same yardstick. However, quality of life is a very subjective measurement. One positive aspect of quality of life measures is that they take patients' concerns into account., The use of the term "quality of life" to encompass the values and perceptions of patients has created doubt, confusion, and misunderstanding among practitioners, researchers, policymakers, and patients. The principal reason for this state of affairs is that a clear conceptual basis for quality-of-life measures is lacking. In this article, the current rationale for quality-of-life measurement in the health field is examined, and the drawbacks of the various models being used are outlined. Our suggestion is that quality of life as an outcome could be explored more clearly (ie, defined) if quality of life were replaced with a more easily handled notion such as that of "subjective health status." However, the idea that the patient's perspective is as valid as that of the clinician when it comes to evaluating outcomes has a great deal of legitimacy and should certainly not be abandoned.

Cases of slowness among patients who spent large amounts of time to perform daily activities were first reported in 1974, and described as primary obsessional slowness (POS). It was observed that it was neither obsessive thoughts nor compulsions that directly hindered their daily activities. However, in more than 20 years following the original report, the diagnostic independence of POS remains controversial, some insisting that obsessional slowness can be explained as secondary. The authors experienced four cases in Japan which share the same characteristics as the original cases. Long-term observation and treatment has led us to support the diagnostic independence of POS. Slowness remained after other accompanying symptoms of obsessive-compulsive disorder had been successfully treated, showing that the slowness of our patients was not secondary.

Purpose: To describe the 'advice or information' people who have had HPV for one year would give to the newly diagnosed. Design: Descriptive Population, Sample: The population was persons with HPV. A convenience sample of 61 women and 27 men, mean age 23.8 years, was recruited from 4 clinics in one midwestern U.S.A. city between 1990 and 1993. Methods: Participants answered an open-ended question about the advice and information they would give to newly diagnosed persons. Content analysis was done. Findings: Six major areas of advice were provided including keeping a balanced perspective, getting treatment, sexual behavior, knowledge, self-care, and other. A high percent of advice from women was to keep a balanced perspective on life. A high percent of the advice from men focused on sexual behavior. Conclusions: Advice covered a variety of topics touching on many aspects of daily life, not simply disease control and sexual behavior. Clinical Implications: Practitioners should carefully explore their clients' reactions to the diagnosis of HPV and address the sensitive emotional elements entailed., Adapting to life with human papillomavirus (HPV) infection, a sexually transmitted disease, takes some effort. HPV patients provided advice on several topics, including keeping a balanced perspective, attention to treatment, sexual behavior, establishing support, and educating oneself. There was less of a focus on safe sex practices than on dealing with the emotional impact of having contagious genital warts. The treatment of HPV infection should extend to psychosocial aspects, such as counseling.

Patients with Alzheimer's disease (AD) show varying degrees of awareness of their deficits. To examine the impact of this phenomenon upon the distress experienced by family caregivers of AD patients, we analyzed caregiver burden in relation to patient awareness of deficit in three different functional domains. The relationship of burden to selected sociodemographic variables was also explored. Results of multiple regression analyses suggested that caregiver burden was associated with impaired patient awareness of memory deficit independent of disease stage and dementia severity. The findings suggest that impaired awareness may be an important mediator of caregiver burden, a concern in the management of AD. Key Words: Dementia, Anosognosia, Insight

Byline: T. H. Hoang Thi (1), F. Guillemin (2), A. Cornette (3), J. M. Polu (3), S. Briancon (2) Keywords: Key words: Quality of life--Chronic obstructive pulmonary disease--Prognosis. Abstract: Chronic obstructive pulmonary disease (COPD) induces changes in daily activities and mood. Health-related quality of life (HRQL) measures are of particular relevance in the management of such patients, but predictors of HRQL have rarely been investigated. The aim of this study was to seek factors predicting HRQL in severe COPD patients under long term oxygen therapy (LTOT). The pulmonary function parameters at the start of LTOT were studied as potential predictors of future HRQL. HRQL was assessed after an average of 40 months follow-up by the Duke Health Profile (Duke) and by the St. George Respiratory Questionnaire (SGRQ). Sixty-one patients (47 males and 14 females) with a mean age of 66 years were included in the study. Stepwise multiple regression analyses conducted in each HRQL dimension identified few significantly predictive factors. By the Duke, higher Self-esteem scores were associated with higher Pao .sub.2 (p &lt 0.01) and with older age (p &lt 0.05) higher Social Health scores were associated with older age (p &lt 0.005), and higher Pain scores were associated with a higher FEV.sub.1/FVC ratio (p &lt 0.05). By the SGRQ, the Activity score correlated with FEV.sub.1/FVC (p &lt 0.05). The proportion of the variance in each score accounted for by covariates in the model did not exceed 10%. No other significant regression models could be identified using the other HRQL dimensions. Our findings demonstrated weak relations between lung function at the start of LTOT and some dimensions of HRQL measured by the Duke and the SGRQ at the end of follow-up. Author Affiliation: (1) Centre Universitaire de Formation et de Perfectionnement des Professionnels de Sante (CUF), Ho Chi Minh ville, VietNam, VN (2) Ecole de Sante Publique, Universite de Nancy and Unite d'Epidemiologie, Hopital Marin Centre Hospitalier Universitaire (CHU), Nancy, FR (3) Association Regionale pour l'Aide aux Insuffisants Respiratoires Chroniques de Lorraine (ARAIRLOR), Vandoeuvre les Nancy and Service des Maladies Respiratoires, CHU Nancy, France, FR Article note: Accepted for publication: 9 July 1996

This study examined the relationship between psychiatric conditions and narcissism in 78 patients with physical rehabilitation for illnesses such as cerebrovascular disease. The frequency of psychiatric disorders (Major Depression and Adjustment Disorder) was significantly higher for the patient group than for the healthy control group. The patients had significantly higher scores on measures of psychiatric symptoms including depression and lower scores on a narcissistic factor (Self-sufficiency) than the controls. In the patient group, the Self-sufficiency scores were significantly and positively correlated with Vigor scores. In the patient and control groups, although the correlation coefficient was not high and no significant difference was noted, the Self-sufficiency scores were negatively correlated with the Depression scores. These findings suggest that, in patients undergoing physical rehabilitation, poor Self-sufficiency is related to a decrease in vigor as a depressive symptom, perhaps due to the loss of physical functioning.

The rates of psychological disorders in patients with acute and chronic temporomandibular joint disorder (TMD) are higher than those in the general population. Persistent pain in the jaw seems to interfere with psychological well-being, especially in chronic TMD. A study of 101 patients with TMD found they had a more frequent diagnosis of anxiety, affective disorders, and paranoid personality compared to general population rates. Dentists should be aware of the additional treatment and referral implications of TMD patients by seeking consultation with other specialists.

An intergenerational community sample of subjects, aged between 24 and 93 years, rates patient's mental capacity and experience of pain as important factors influencing life-sustaining treatment decisions. Care burden on family, financial strain, and patient's age are the least important factors. However, the oldest generation tend to rate the latter three factors as important. Discrepancy exists between the ratings of adult children and their parents regarding life-sustaining treatment decisions.

100 patients with chronic pain judged 'problematic' by their referring physicians were administered the Wechsler Adult Intelligence Test-Revised. 38 obtained IQs of 85 or less while only 11 earned IQs of 101 or higher. While a number of confounds may have influenced these results, low intelligence appears to be a marker for negative treatment prognosis, at least as perceived by physicians, and its influence would seem to merit further investigation and clarification.

A hazard of being a physician is encountering patients or their family members who have abusive or violent behavior. Physicians cannot prevent violent attacks from happening, but they can draw up measures to protect themselves when such incidents occur. However, they should never commit actions that will injure these patients because they might also injure themselves in the process. The best course would be to wait until the patients calm down or to call for help when the attacks become uncontrollable., Doctor, I don't care if it is cancer. If you remove my wife's breast, I'm going to blow your brains out!' The general surgeon in Georgia who received that phone [...]

It has been proposed that high anxiety sensitivity amplifies a number of fears and anxiety reactions. The purpose of this study was to examine whether anxiety sensitivity influences pain-related anxiety and associated cognitive and affective reactions in patients with physically unexplained chronic back pain. Seventy patients with chronic back pain without demonstrable organic pathology completed a battery of questionnaires prior to admission to a multidisciplinary treatment centre. Fourteen patients (20.0%) were classified as high, 44 (62.9%) as medium and 12 (17.1%) as low anxiety sensitive. Multivariate analysis of variance indicated that the high anxiety sensitive patients were more negatively affected by their experience with pain. Specifically, high anxiety sensitivity patients exhibited greater cognitive disruption and anxiety in response to pain, greater fear of negative consequences of pain, and greater negativity of affect than the other groups. Groups did not differ in the intensity of pain that they were experiencing. The proportion of high anxiety sensitive patients reporting current use of analgesic medication was, however, significantly greater than the medium and low anxiety sensitive patients. Correlational analyses indicated significant associations between anxiety sensitivity and pain-related cognitive/affective variables that were independent of pain severity. These results suggest that chronic back pain patients with high anxiety sensitivity, despite equal levels of pain severity, are more likely to be negatively affected by their pain experiences than those with medium and low anxiety sensitivity.

Social factors related to perfectionism contribute to poor family adjustment. Research assessed the social dimensions of perfectionism and relationship adjustment. A sample of 83 chronic pain patients with a mean age of 43 years and median income of $45,000, including 41 men and 41 women and their spouses, participated in the study. These people completed the Multidimensional Perfectionism Scale, Adjustment Scale and Beck Depression inventory.

Despite considerable research, low back pain (LBP) often proves resistant to treatment. This study was designed to increase the understanding of low back pain through access to patients' perceptions, beliefs, illness behaviors and lived experiences. The findings are based on focus groups, individual interviews and participant observation conducted in primary care practices and community settings in three regions in Israel. Inclusion criteria for the interviews and groups include age greater than 18 years and a history of at least one episode of LBP. Seventy-six LBP subjects between the ages of 18 and 67 (mean 39.5) participated, 65% male and 35% female. The analytic method is content analysis, consisting of a formal, multi-step process designed to elucidate inherent patterns and meanings. This research finds that LBP subjects articulate a rich world of pain sensation, awareness and meanings. From subjects' own words and experiences we present a patient-centered classification system of backache symptoms based on typical pain intensity, dysfunction, duration and treatment. An elaborate system of explanatory models of LBP and a typology of dominant coping styles designed to either minimize pain or maximize function are also derived. Subjects choose multiple conventional and alternative treatments based on 'what works,' and articulate ample criticisms of and suggestions for the medical system. In addition, we find that variations in the social construction of the back pain experience vary sharply, even between similar neighboring communities. Given the difficult state of diagnosis and treatment and the frustration of practitioners, attempts at greater understanding of patients' health beliefs, experiences, and behaviors are warranted. Reaching agreement between health provider and patient and addressing patient belief systems may improve outcomes. Key words - low back pain, patient-centered, explanatory models

Previous research led to the conclusion that patient characteristics such as physical attractiveness and non-verbal expressiveness affected judgements of patient pain and distress. This study investigated whether this represents an intrusive bias or whether there indeed are psychological differences between physically attractive vs physically unattractive and expressive vs inexpressive pain patients. The findings led to the conclusion that both variables are related to the types of coping strategies pain patients use. Specifically, physically attractive and nonverbally expressive patients were found to be less likely to utilize passive coping strategies. Coping style also was found to be related to demographic characteristics of the patients. Theoretical reasons for the identified relationships are discussed as are the implications of these findings for the assessment of pain. Key words - physical attractiveness, pain, non-verbal expressiveness

I use statistical data to describe the populations of malpractice claims in New York and Massachusetts, and in-depth interviews with physicians and claimants to explore the human side of medical malpractice claims. I argue that medical malpractice claims are associated with tertiary medical care delivered within a business setting. Several major themes emerge from my analysis. There is a strong distinction between physicians' and claimants' definitions of medical outcomes. Physicians judge medical outcomes in terms of generally accepted medical practice. In contrast, patients judge medical outcomes in terms of how their lives have changed. Physicians voice their concerns about the uncertainty in the practice of medicine. Marginalization, which occurs when physicians push their patients' personal and social concerns related to their treatment to the periphery, is a major concern of claimants. The physicians' interviews also contain themes of anger, distrust of patients, and defensive medicine; patients' themes include anger, vindication, and deference towards their former physicians. Finally, some physicians and claimants view medicine more as a business rather than as a humanistic institution.

There has been a lack of research on the understanding of inpatient groups. To understand their psychology it requires a different approach than the outpatient setting. The theoretical basis of outpatients such as instillation of hope, group cohesiveness, catharsis and altruism that has been applied to understand inpatient conditions do not satisfactorily serve the purpose. Differential models of Yalom (1983), and Froberg and Slife (1987); problem solving models of Sautter, Heaney and O'Neill (1991); and closed model of Brabender (1988) are discussed.

We describe the use of the 40-item Threat Index (TI) with family members (N = 206) of surgical patients who also completed Templer's (1970) Death Anxiety Scale, the Death-of-Self and Dying-of-Self subscales of the Collett-Lester (1969) Fear of Death Scale, and the Death Acceptance subscale of Reker and Peacock's (1992) Life Attitude Profile - Revised. Word sets from the 40-item TI that are part of the 25- and 7-item versions of the TI produced strong alphas and correlations to their parent instrument. Regression analyses indicated that self/ideal-self scores and previous experience as a hospital patient were significantly associated with TI scores. We conclude that if the time available for completion and scoring of the TI is limited, the shorter versions can be used, although their alpha strengths are slightly lower than that of the full TI and the respondent's age influences the scores.

In the present study, 14 psychotherapy clients were interviewed about their recollections, assisted by tape replay, of an immediately preceding therapy session. A major category derived from a grounded theory analysis of the interview protocols was client's deference to the therapist, constituted of 8 lower level categories: concern about the therapist's approach, fear of criticizing the therapist, understanding the therapist's frame of reference, meeting the perceived expectations of the therapist, accepting the therapist's limitations, client's metacommunication, threatening the therapist's self-esteem, and indebtedness to the therapist. The P. Brown and S. Levinson (1987) model of politeness in discourse both informs and is informed by the results of this study, which are also discussed in terms of recent literature on the client's covert experience and in terms of their implications for the practice of therapy.

In this paper the content of everyday mastery is described, and related background variables are analyzed. Health maintenance, self-care practices, coping resources and feelings of helplessness, as indicators of daily mastery, were studied among a group of 142 Finnish primary care patients using a two-week diary method. The main themes related to health maintenance, self-care, and coping resources were found to be: meaningfulness of life, social relations and togetherness, activities, recreation and enjoyment, discipline and good health, and treatment of symptoms and diseases. The most frequent causes of feelings of helplessness were: diseases and symptoms, discrepancies between demands and capabilities, and negative psychological and emotional states. When writing about mastery, women mentioned philosophy and faith, social relations and togetherness, as well as food and dieting more often than men. Women recorded more helplessness due to discrepancies between demands and capabilities and to negative psychological and emotional states, whereas men recorded more helplessness due to global, political, and societal conditions. Older people recorded philosophy and faith and lay care more frequently as sources of mastery more than younger people. Helplessness due to the discrepancies between demands and capabilities was more evident among older people.

The findings of a study that explored the beliefs, assumptions and ideas nurses have about the coping of patients are presented. Interactive interviews with 26 nurses were used to elicit explanations of the meaning of coping and stories from their practice that illustrated coping. Analysis of the interview transcripts revealed three themes in the form of idioms or particular and different ways of talking about coping. Each idiom represented a different perspective or view of coping. The first idiom represented a view of coping as a rational, cognitive problem-solving response to illness. The nurses attributed, and thus valued, this view to science. In the second idiom the nurses spoke of coping as permeated with values that contrasted with the prior view of coping as a rational process. In the final idiom the nurses spoke of coping as courage - they told stories of patients who had faced existential situations with strength and will. The focus of this idiom was on issues of spirituality, struggle, personal meaning and acceptance. After each idiom is delineated and illustrated by data, the discussion is concentrated on the orientational and ontological metaphors that underlie them. Interpretation of the origin and construction of these different ways of talking about coping, and their underlying metaphorical meanings, is made in the context of cultural and subcultural influences.

Awareness of folk beliefs and their effect on illnesses should aid practitioners in treating their patients. Folk illnesses are those not defined in standard Western medical practice. Folk illnesses may be cultural interpretations of certain diseases. Practitioners should be aware of folk beliefs because patients may seek treatment from Western medicine and folk therapists simultaneously. Also, some folk remedies may be dangerous. Practitioners should inquire about causes of an illness in a non-judgemental manner. Patients are more likely to hold folk beliefs about illnesses if they have strong ties to their country of origin, use their first language more often and were educated in their country of origin. Practitioners may be able to collaborate with folk healers in treating patients., This article presents an approach to the evaluation of patient-held beliefs and behaviors that may not be concordant with those of biomedicine. Physicians and patients often hold discrepant models of health and illness that may affect the effectiveness of communication during the clinical visit. An extreme example of such a discrepancy exists when the patient feels that he or she has an illness that is not defined within the biomedical paradigm. These are commonly referred to as folk illnesses. An example of such an illness is provided in order to discuss the effects of folk beliefs on patient-held perceptions of health and sickness, treatment-seeking behavior, clinical care, and physician-patient communication. Guidelines for addressing clinical issues surrounding folk beliefs and behaviors in a culturally sensitive way are discussed.

In this paper we discuss the measurement of spiritual, religious and philosophical beliefs in patients admitted to hospital with acute physical illness. The discussion is based on the results of a preliminary study of the beliefs of 300 patients studied by face- to-face interview and questionnaire. Principal outcome measures at 6 months were self reported psychological and belief scores and physical state as reported in the medical records. Two thirds of patients reported a religious and/or spiritual belief system. Strength of belief was not associated with social, psychological or diagnostic factors. However, those patients with a religious and/or spiritual life view who expressed strong beliefs were likely to fare less well clinically. We conclude that empirical study of patients' beliefs is possible, though care must be exercised over the measures used. Beliefs were at least as predictive of outcome as other social and psychological factors. This area is of considerable importance to patients and should not be neglected by carers or researchers.

A series of three studies of consecutive primary care patients examined their intentions when visiting a general practitioner (GP). In study 1, a principal, components analysis of responses to a specially-devised symptom check-list was used to form component-based scales on which patients' physical symptoms were scored. Apart from a modest association of cold symptoms with seeking simple explanation, physical symptoms were unrelated to intentions. By contrast, the level of psychological symptoms correlated with the desire for support from the GP. In study 2 this result was replicated and shown to be unaffected by the amount of support which patients already experienced from family and friends. In study 3, GPs were found to be able to detect at better than chance level which patients desired support, but they were insensitive to other intentions. The results indicate that a technique for the quantification of patients' intentions permits the formal investigation of important questions concerning primary care consultations.

A commitment-based intervention was evaluated for improvement of adherence to a 10-day antibiotic regimen. Experimental Ss made verbal and written commitments for adherence and completed tasks designed to increase their investment in a medication regimen. Control Ss performed similarly structured tasks unrelated to the medical regimen. Adherence, measured by unannounced pill counts, was significantly higher for experimental subjects than for control Ss. Self-reported adherence was significantly correlated with posttest self-efficacy but not with pretest self-efficacy. Adherence to a medical regimen may be improved by strategies conceptually based on the investment model of commitment, which provides a useful framework for further study of adherence.