Faculty Bibliography

OBJECTIVES: To describe patterns of interruption in the physician-patient interaction; specifically, to determine who interrupts, to determine if a shift in control occurs as a result of interruption, and to characterize the information gained when patients interrupt physicians. DESIGN: Observational. SETTING: Community-based primary care practices in North Carolina. SUBJECTS: Internists and family physicians in private practice in North Carolina (six men and two women) and their patients (13 men and 27 women). INTERVENTIONS: None. MAIN OUTCOME MEASURE: The obtainment of control of the interaction, at least momentarily, as a result of interruption. RESULTS: Analysis of 40 audiotaped interactions revealed 833 interruptions (mean +/- SD, 20.8 +/- 12.2 per interaction): Patients initiated 55% of all interruptions. Physicians and patients each gained control of the conversation after 50% of interruptions. Patients gained control after 74% of patient-initiated interruptions, and physicians gained control after 79% of physician-initiated interruptions. Patients were more likely to gain control by interrupting late in the interaction, and 75% of patient-initiated interruptions resulted in new information (solicited and unsolicited) being contributed to the interaction. CONCLUSION: Interruption by patients can be an informative event

In dealing with a famous patient in an emergency, a doctor's reaction, like anyone's, can be emotional, and [Josh] Schwartzberg is one of the rare ones to publicly bare his feelings about the experience. In the first few seconds, Schwartzberg said, he was shocked by the sudden, inexplicable collapse of an apparently healthy world-class athlete. But Schwartzberg quickly joined in a drill that he had led many times in 22 years as a family practitioner. Whether [Sergei] Grinkov's regular doctors felt the world was looking over their shoulders is not known. If they had taken his high blood pressure seriously, Schwartzberg now believes, they might have detected Grinkov's heart disease when treatment could have saved his life. Grinkov's heart stopped while he and [Yekaterina] Gordeyeva were practicing for an ice show. Grinkov said he felt dizzy and gently slumped to the ice. At first, those around Grinkov thought he had been seized with a recurrence of low back pain and sciatica and wanted to rest on the ice. But Grinkov did not respond. So his coach immediately started CPR in front of Gordeyeva and other shocked onlookers. He was soon joined by an emergency medical technician who was in the arena

Harry Kaufman, a token clerk who suffered severe burns and smoke inhalation when two men torched his subway booth, is in the burn unit at New York Hospital-Cornell Medical Unit in Manhattan NY. The difficulty in treating someone who has suffered third-degree burns that cover 80 percent of the body as well as lung damage from smoke inhalation is discussed

Mr. Grinkov's heart stopped while he and Ms. Gordeyeva were practicing for an ice show. Mr. Grinkov said he felt dizzy and gently slumped to the ice. At first, those around Mr. Grinkov thought he had been seized with a recurrence of low back pain and sciatica and wanted to rest. But Mr. Grinkov did not respond. So his coach immediately started CPR in front of Ms. Gordeyeva and other shocked onlookers. He was soon joined by an emergency medical technician who was in the arena. 'Although it now seems clear that he was dead from the beginning, as time went on you just felt life slipping away and the likelihood of recovery less and less, and finally you resort to putting a needle in the heart' to inject a stimulant, epinephrine, Dr. Schwartzberg said. When the last ditch effort was unsuccessful, Dr. Schwartzberg said he had 'the painful but agonizing decision of saying, this is futile, let's not go any further.' He pronounced Mr. Grinkov dead. Mr. Grinkov's death was a medical mystery, and an autopsy would be performed because this was a death that could not be explained by a personal physician. Dr. Schwartzberg knew there would be speculation about what had caused Mr. Grinkov to die. So he made a point of discussing the autopsy with Ms. Gordeyeva and seeking her consent for it. There had been no history of abusing drugs, but Dr. Schwartzberg and the pathologist wanted toxicology tests to be sure. She agreed.

'Who thinks a healthy world-class athlete age 28 exercising vigorously without symptoms would have coronary artery disease,' Schwartzberg said. 'This is an enigma. But it happens and is hard to understand. Everyone in the emergency room who dealt with this situation was just in a daze afterward; it is so unbelievable.' 'If you have a familial tendency to have atherosclerotic heart disease, it does not matter really whether you are an athlete or not,' Varga said. 'Because if you are an athlete, that does not make you immune to the effects of coronary artery disease.' 'At least today we have clarity and understanding,' Schwartzberg said. 'We know exactly what happened and it does make sense, as rare an event as it was.'

When Dr. Valavanur A. Subramanian ran a scalpel along Edward Dowling's left fourth rib to make a three-inch incision from near the nipple to the breast bone one day last month, the operating room at Lenox Hill Hospital in Manhattan was eerily silent. The operation on Dowling, a 66-year-old piano tuner, involved a new procedure known as minimally invasive direct coronary bypass surgery. Instead of stopping the heart and having a heart-lung machine take over its duties, Subramanian's team performed a delicate operation on the organ as it continued to beat. Subramanian's approach is one of several ways minimally invasive coronary bypass surgery is being done. Some versions are modeled after the video-assisted, fiber-optic techniques developed for gallbladder and other surgeries. Others have modified decades-old methods to sew arterial grafts onto beating hearts without using heart-lung machines. 17

When Dr. Valavanur A. Subramanian ran a scalpel along Edward Dowling's left fourth rib to make a three-inch incision from near the nipple to the breast bone, the operating room at Manhattan's Lenox Hill Hospital was eerily silent. The operation ealier this month on Dowling, a 66-year-old piano tuner, involved a new procedure known as minimally invasive direct coronary bypass surgery. Instead of stopping the heart and having a heart-lung machine take over its duties, Subramanian's team performed a delicate operation on the organ as it continued to beat. As a heart-lung machine temporarily pumps oxygenated blood through the body, a surgeon takes veins from a leg, an artery from the chest, arm or abdomen, and sews it to a coronary artery. The graft restores adequate blood flow by bypassing a blockage caused by a build-up of fatty deposits

[Janet Reno]'s physician, Jonathan Pincus, said Reno has mild [Parkinson]'s disease that is fully controlled with medication. The tremor in her left hand is Reno's only symptom from Parkinson's, Pincus said in an interview. Parkinson's typically begins insidiously and Reno's case was no exception. She said the shaking in her hand began almost imperceptibly last spring, and she thought it would go away. But when it did not, she consulted her doctor. Pincus said he 'would anticipate no serious disability from Parkinson's disease for Reno for 15 to 20 years and even then she should be fine,' although there is no guarantee she will not develop other disorders

WASHINGTON - Attorney General Janet Reno disclosed Thursday that she has developed Parkinson's disease, but she said she planned to stay on the job. Reno, who is right-handed, said the tremor is fully controlled by Sinemet, a pill she has been taking three times a day since the condition was diagnosed three weeks ago. Reno's physician, Dr. Jonathan H. Pincus, professor and chairman emeritus of the neurology department at Georgetown University Medical Center, said Reno has mild Parkinson's disease that is fully controlled with medication. The tremor in her left hand is her only symptom from Parkinson's, Pincus said in an interview