Annals of internal medicine
-
Actual teaching at the bedside during attending rounds, with emphasis on history taking and physical diagnosis, has declined from an incidence of 75% in the 1960s to an incidence of less than 16% today. Profound advances in technology, in imaging, and in laboratory testing and our fascination for these aspects of patient care, account for part of this decline, but faculty must also assume responsibility for the present lack of bedside teaching. ⋯ And if we are to become effective bedside teachers, as were our mentors, we will need to sharpen our own physical diagnostic skills. We will need to learn how to be gentle with students and housestaff, how to better communicate with patients, and how to teach ethics and professionalism with the patient at hand.
-
Support for the participation of physicians in the suicides of terminally ill patients is increasing, and the concrete effects on physician practice of a policy change with regard to physician-assisted suicide must be carefully considered. If physician-assisted suicide is legalized, physicians will need to gain expertise in understanding patients' motivations for requesting physician-assisted suicide, assessing mental status, diagnosing and treating depression, maximizing palliative interventions, and evaluating the external pressures on the patient. They will be asked to prognosticate not only about life expectancy but also about the onset of functional and cognitive decline. ⋯ Protection of the patient's right to confidentiality must be balanced against the need of health care professionals and institutions to know about the patient's choice. Insurance coverage and managed care options may be affected. All of these issues need to be further explored through research, education, decision making by individual practitioners, and ongoing societal debate.
-
Alleviating the problems faced by dying persons and their families has drawn substantial public attention, but little is known about the experience of dying. ⋯ Most elderly and seriously ill patients died in acute care hospitals. Pain and other symptoms were commonplace and troubling to patients. Family members believed that patients preferred comfort, but life-sustaining treatments were often used. These findings indicate important opportunities to improve the care of dying patients.
-
To review the literature on the effects of amiodarone on thyroid physiology and management of amiodarone-induced thyroid disease. ⋯ Thyroid dysfunction commonly occurs with amiodarone therapy. It may be difficult to recognize the dysfunction because of the many changes in thyroid function test results that occur in euthyroid patients who are receiving amiodarone. Effective strategies exist for the management of hyperthyroidism and hypothyroidism; these should be tailored to the needs of the individual patient.
-
It is widely presumed that the development of postoperative hyponatremia (which may be severe) results from administration of hypotonic fluids while antidiuretic hormone is acting. ⋯ Postoperative hyponatremia occurred within 24 hours of induction of anesthesia when only near-isotonic fluids were infused. Hyponatremia was generally caused by generation of electrolyte-free water during excretion of hypertonic urine-a desalination process. This electrolyte-free water was retained in the body because of the actions of antidiuretic hormone. If the pathophysiology of this hyponatremic state is understood, recommendations for its prevention and treatment can be deduced.