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We describe prostaglandin (PG) biosynthesis by isolated midgut preparations from tobacco hornworms, Manduca sexta. Microsomal-enriched midgut preparations yielded four PGs, PGA/B(2), PGD(2), PGE(2) and PGF(2alpha), all of which were confirmed by analysis on gas chromatography--mass spectrometry (GC--MS). PGA and PGB are double bond isomers which do not resolve on TLC but do resolve by GC; for convenience, we use the single term PGA(2) for this product. PGA(2) was the major product under most conditions. The midgut preparations were sensitive to reaction conditions, including radioactive substrate, protein concentration (optimal at 1mg/reaction), reaction time (optimal at 0.5 min), temperature (optimal at 22 degrees C), buffer pH (highest at pH 6), and the presence of a co-factor cocktail composed of reduced glutathione, hydroquinine and hemoglobin. In vitro PG biosynthesis was inhibited by two cyclooxygenase inhibitors, indomethacin and naproxen. Subcellular localization of PG biosynthetic activity in midgut preparations, determined by ultracentrifugation, revealed the presence of PG biosynthetic activity in the cytosolic and microsomal fractions, although most activity was found in the cytosolic fractions. This is similar to other invertebrates, and different from mammalian preparations, in which the activity is exclusively associated with the microsomal fractions. Midgut preparations from M. sexta pupae, adult cockroach, Periplaneta americana, and corn ear worms, Helicoverpa zea, also produced the same four major PG products. We infer that insect midguts are competent to biosynthesize PGs, and speculate they exert important, albeit unrevealed, actions in midgut physiology.

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Nodulation is the first, and qualitatively predominant, cellular defense reaction to bacterial infections in insects. We tested the hypothesis that eicosanoids also mediate nodulation reactions to bacterial challenge in adults of a social insect, the honey bee, Apis mellifera. Treating newly-emerged experimental bees with the eicosanoid biosynthesis inhibitor, dexamethasone, impaired nodulation reactions to bacterial infections, and the influence of dexamethasone was reversed by treating infected insects with arachidonic acid, an eicosanoid precursor. Several other eicosanoid biosynthesis inhibitors, including the cyclooxygenase inhibitor, indomethacin, and the dual cyclooxygenase/lipoxygenase inhibitor, phenidone, also impaired the ability of experimental honeybees to form nodules in reaction to bacterial challenge. The influence of phenidone on nodulation was expressed in a dose-dependent manner. However, in experiments with older honey bees foragers, similar bacterial challenge did not evoke nodulation reactions. We infer from our results that while eicosanoids mediate cellular immune responses to bacterial infections in newly emerged honey bees, and more broadly, in most insect species, nodulation reactions to bacterial challenge probably do not occur in all phases of insect life cycles.

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This study investigated the extent to which the individual orientations of physicians and patients and the congruence between them are associated with patient satisfaction. A survey was mailed to 400 physicians and 1020 of their patients. All respondents filled out the Patient-Practitioner Orientation Scale, which measures the roles that doctors and patients believe each should play in the course of their interaction. Patients also rated their satisfaction with their doctors. Among patients, we found that females and those who were younger, more educated, and healthier were significantly more patient-centered. However, none of these variables were significantly related to satisfaction. Among physicians, females were more patient-centered, and years in practice was related to satisfaction and orientation in a non-linear fashion. The congruence data indicated that patients were highly satisfied when their physicians either had a matching orientation or were more patient-centered. However, patients whose doctors were not as patient-centered were significantly less satisfied.

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OBJECTIVES: To use audiotape analysis to describe communication patterns in primary care, to relate these to ideal relationship types as described in the literature, and to explore the patterns' relationships with physician and patient characteristics and satisfaction. DESIGN: Description of routine communication in primary care based on audiotape analysis and patient and physician exit questionnaires. SETTING: A total of 11 ambulatory clinics and private practices. PARTICIPANTS: The participants were 127 physicians and 537 patients coping with ongoing problems related to disease. MAIN OUTCOMES MEASURES: Roter Interactional Analysis System (RIAS) and patient and physician exit satisfaction questionnaires. RESULTS: Cluster analysis revealed 5 distinct communication patterns: (1) "narrowly biomedical," characterized by closed-ended medical questions and biomedical talk occurring in 32% of visits; (2) "expanded biomedical," like the restricted pattern but with moderate levels of psychosocial discussion occurring in 33% of the visits; (3) "biopsychosocial," reflecting a balance of psychosocial and biomedical topics (20% of the visits); (4) "psychosocial," characterized by psychosocial exchange (8% of visits); and (5) "consumerist," characterized primarily by patient questions and physician information giving (8% of visits). Biomedically focused visits were used more often with more sick, older, and lower income patients by younger, male physicians. Physician satisfaction was lowest in the narrowly biomedical pattern and highest in the consumerist pattern, while patient satisfaction was highest in the psychosocial pattern. CONCLUSIONS: Primary care communication patterns range from narrowly biomedical to consumerist patterns and parallel the ideal forms of patient-physician relationships described in the literature.

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Medical interviews (consultations) are composed of verbal exchanges, complementary categories of speech by patients and clinicians that tend to occur together. Patients and clinicians employ a joint repertoire of exchanges to accomplish their goals in the encounter. The seven principal exchanges are called Exposition, Closed Question, Checking, Direction, Inquiry, Explanation, and Instruction/Contracts. We discuss how the verbal exchange structure contributes to understanding the confluence of patients' and clinicians' goals and expectations, clinicians' hypothetico-deductive method of reasoning during interviews, and establishing the patient-clinician relationship. We conclude by considering new exchanges that might make medical interviewing more effective and humane.

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The verbal exchange theory of medical interviews (consultations) proposes that patients and clinicians employ a joint repertoire of exchanges to accomplish their goals in the encounter. The skeleton of each exchange is a set of speech acts that tend to be used together in interviews, for example, (a) clinician questions and patient yes/no answers, or (b) clinician directives and patient agreements to comply. We describe seven principal exchanges, each of which has been identified empirically in multiple studies of interviews: Exposition, Closed Question, Checking, Direction, Inquiry, Explanation, and Instruction/Contracts.

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The results of previous studies on the relationship between patient satisfaction and specific interviewing behaviors have been difficult to generalize because most studies have examined small samples of patients at one clinical location, and have used initial or acute care visits where the patient and physician did not have an established relationship. The present collaborative study of medical interviewing provided an opportunity to collect interviews from 550 return visits to 127 different physicians at 11 sites across the country. Tape recordings were analyzed using the Roter Interaction Analysis System, and postvisit satisfaction questionnaires were administered to patients. A number of significant relationships were found between communication during the visit and the various dimensions of patient satisfaction. Physician question asking about biomedical topics (both open- and closed-ended questions) was negatively related to patient satisfaction; however, physician question asking about psychosocial topics was positively related. Physician counseling for psychosocial issues was also positively related to patient satisfaction. Similarly, patient talk about biomedical topics was negatively related to satisfaction, while patient talk regarding psychosocial topics was positively related. Furthermore, patients were less satisfied when physicians dominated the interview by talking more or when the emotional tone was characterized by physician dominance. The findings suggest that patients are most satisfied by interviews that encourage them to talk about psychosocial issues in an atmosphere that is characterized by the absence of physician domination.

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To study the effects of teaching specific interviewing techniques on verbal behaviors and on health outcomes, internal medicine residents working in a screening clinic were assigned to either an experimental or a control group. The entire clinic visit was audiotaped, transcribed, and coded according to the Verbal Response Mode (VRM) system. Residents in the experimental group were taught interviewing behaviors (patient exposition and physician explanation) that had been found in previous studies to be associated with patient outcomes. Through telephone interviews, patient satisfaction, compliance, and symptom status were determined for all patients. Two hundred and sixty-eight interviews (156 in the experimental group and 112 in the control group) were included in the study. Training did increase patient exposition and physician explanation, but did not affect health outcomes. Residents' attitudes and behaviors during the training are described.

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To replicate an earlier study and explore associations between verbal behaviors in patient-physician interactions and outcomes of care, 102 visits to a medicine walk-in clinic were tape-recorded, transcribed, and coded according to the Verbal Response Mode (VRM) system. Questionnaires given before and after the clinic visit and telephone interviews 1 week and 4 weeks after the visit were used to measure patient satisfaction, compliance, and change in symptoms. Data were collected on patients' sociodemographic characteristics, illness characteristics, and health beliefs. Two verbal exchanges were examined: in the medical history, the Patient Exposition exchange, which was measured as the frequency with which patients make statements about their illnesses in their own words; and in the conclusion, the Physician Explanation exchange, which was measured as the percentage of physician statements that are factual. These verbal indexes showed correlations with patient satisfaction, thus replicating the earlier study, but no significant correlations with compliance. Analysis of variance showed that the association between verbal exchanges and patient satisfaction remained after controlling for physician differences and for patient age, education, and belief in the controllability of the illness.

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The medical record is the source of information for many purposes, including evaluation of the quality of care provided. Despite this reliance on the record, there have been few attempts to validate the recorded content against the verbal content of the interaction between patient and physician. In this study, we compared the record with verbatim transcripts of outpatient visits. Overall, 59 per cent of units of information present in either source were found in the record. Recording was more complete for the chief complaint (92 per cent) and information related to the patient's present illness (71 per cent) than for other medical history (29 per cent). Incomplete recording of elicited information may partially explain the often low levels of performance of recommended care items found in quality-of-care studies. We suggest that more attention be paid to improving communication about tests and therapies to patients.

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The verbal interaction between patients and physicians in 52 initial interviews in a university hospital screening clinic was studied using a new discourse coding system. Factor analysis of category frequencies showed that each interview segment, medical history, physical examination, and conclusion, consisted mainly of two or three types of verbal exchange. Patient satisfaction with the interviews, assessed with a questionnaire that yields separate scores for satisfaction with cognitive and affective aspects, was found to be associated with exchanges involving the transmission of information in particular interview segments. Affective satisfaction was associated with transmission of information from patient to physician in "exposition" exchanges during the medical history, in which patients told their story in their own words. Cognitive satisfaction was associated with transmission of information from physician to patient in "feedback" exchanges during the conclusion segment, in which physicians gave patients information about illness and treatment.

PIP: Analysis of the verbal interaction between physicians and patients in 52 initial interviews at a university hospital screening clinic found a strong association between patient satisfaction and the provision of information. Factor analysis identified 2 principal types of verbal exchange in the medical history (exposition and closed question), 2 in the physical examination (further data and physical examination) and 3 in the conclusion (final clarification, feedback, and patient termination). Affective satisfaction, defined as patients' perceptions of warmth and understanding from their doctor, was associated with exposition exchanges in the medical history--i.e., patients being permitted to tell their story in their own words. Cognitive satisfaction--the patient's feeling that they understand their illness and its treatment--was associated with feedback exchanges in the interview's conclusion, i.e., physicians' giving objective information. The positive relationship between patient satisfaction and certain verbal interactions that enhance the exchange of information has been noted in previous surveys of patient satisfaction. The taxonomy of verbal response modes use in this study is a sensitive, flexible system that makes clinically relevant distinctions beyond the scope of other coding systems. Its use should be considered for further research on the effects of medical encounters and for specifying effective interviewing skills.

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The medical importance of the patient-physician relationship is widely acknowledged, but research on its effects has been hampered by the lack of a method to quantify its clinically relevant features. In this study a new method of coding verbal interaction was applied to 52 interviews with adults in a general medical screening clinic. "Average interaction profiles" for patients and for physicians in the medical history, physical examination, and conclusion segments of the interviews provided detailed descriptions of the relationship that appear to be accurate and coincide with descriptions derived from clinical experience, textbooks, and other studies. The profiles yield quantitative indexes of such crucial aspects of the relationship as the manner in which patients give a history and physicians trasmit information to patients.

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Patient satisfaction is a variable of increasing interest to researchers, clinicians, and medical educators. Of several studies reviewed, only a few have shown evidence of careful methodology. Most surveys have focused on general evaluations of doctors and/or health care services or of a particular facility. The present article reports the development of a scale to measure patient satisfaction with an encounter with a physician or other primary care provider. Methods of item generation and pretesting are detailed. The overall reliability of the scale (Cronbach's coefficient alpha) is 0.93. The distribution of satisfaction scores is broader than that reported for other scales and approaches the normal in shape. Clinical and research applications of the scale are suggested.

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A survey to measure physician receptivity to nurse practitioners was conducted in North Carolina in 1973. All North Carolina physicians were asked to rate a list of 35 clinical tasks of varying levels of difficulty and responsibility according to their willingness to delegate these tasks to nurse practitioners. Using eight items from this list that were good discriminants of physician attitudes towards delegating responsibility, task delegation scores were correlated with physician characteristics and their responses to questions about recruitment, training, reimbursement, and willingness to hire nurse practitioners. Thirty-four per cent of the respondents would hire a nurse practitioner, whereas 52% approved of the concept but would not hire one. Physicians who had previously worked with a nurse practitioner were more willing to hire one and had a higher task delegation score. Sixty-eight per cent of respondents would share their load with nurse practitioners in their offices, while 6% would have them work in satellite clinics away from the physicians' offices. Most physicians wanted their own nurse trained as a nurse practitioner in a program that combined a didactic course at a medical center with on-the-job training. The authors conclude that there is a potential demand for nurse practitioners in North Carolina and that the training program must prepare the nurse practitioners for the tasks physicians are willing to delegate to them.

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